work on differentiating between confusions strains and sprins dislocations the management of fractures complications to fractures which we've already kind of touched upon right fracture reduction immobilization and management including that of casting so we got a bit to get through up first muscular skeletal injuries in and of themselves looking specifically at contusions sprains and strains great so what is a contusion um that'ss almost like a big bruise that is one way of calling it right it's a soft tissue injury right and it usually presents and has bruising Associated swelling tenderness but again some of that bruising does it impact your bone yeah it can maybe I don't know maybe depending on where it is could you have a contusion on top of worsening injuries yes but a contusion in of itself is damage to the soft soft tissue soft tissue right so is there damage to the bone with a plain contusion no no no right how about a strain what is impacted with a strain we think muscles right so pulled muscles overuse right overuse sometimes that kind of wrong improper body mechanics right twisting stretching how about a spin with a P that is joints ligs ligaments ligs right your brain right with the p not the t is ligaments same deal right it's that overuse trauma wrenching twisting now the doctor is typically the one responsible for determining the severity of this they do grade them okay but how do we treat them are any of these going to kill you no no right are any of these going to be life altering depends on how severe maybe for a little while shortterm shortterm okay we'll talk short term maybe right alterations how do you think we approach them all R rest rest let heal give it time to heal right rice right to focus on that rest ice compression and elevation right now when we think rest guys what does that mean what is rest me usually it's off of it weight off of it some people kind of look at it but it's like stop using that extremity to the best of your ability right now that doesn't mean you need to go buy a bed pan and use a bed pan because you can't walk to the bathroom right but it does mean if you're not actively trying to walk to the bathroom no walking right so rest we want to kind of limit that that movement of the affected area how long does that last depends days to weeks sometimes it will impact like based on the severity but typically we look at like 3 to five days right and your typical kind of healing process there's always edema so usually I like to warn people that day two day three is usually worse right in the first day due to some of that swelling right your joint your your muscles and everything get a little bit stiffer from that inactivity right so there might be a little bit more discomfort when we think about ice how does that work so ice does help that basil constriction right and it does decrease in swelling so how do I apply it usually two days after oh so I got two different answers one gave me the physical application which is very important too should be putting direct ice on the injury no no usually we want it like within some type of barrier right towel 20 minutes on minutes off and then in addition to the physical application guys there's a time frame associated with it right there's about it to be a bunch of number I'm going to say it over and over again I promise okay so you can ice that area the affected area for about 20 to 30 minutes every one to two hours for the first 24 to 48 hours so you can use ice every 20 to 30 minutes every 1 to 2 hours for the first 24 to 48 hours one more time for good measure okay ice every 20 to for 20 to 30 minutes every 1 to 2 hours for the first 24 to 48 hours that's the true way to use ice and again it helps with that phase of constriction and it helps decrease swelling after that 48 Hours guess what you get to switch to heat and what does heat do helps promote circulation and healing it baso dilates to promote perfusion right and help with that healing process but we don't do it the same actually using heat can like too much heat can actually cause more more damage so there's time FR for that too yeah there sure are right who wants to guess yeah 15 to 30 minutes four times daily right so he is going to start after that 48 hour mark for about 15 to 30 minutes four times a day that's a big difference what are we talking about when we talk compression bandages Ace bandages stuff to Ace bandages can we also use like immobilization immobilization like braces right can also be supportive what education do you need to discuss and provide the patient when it comes to compression want to look for signs that it's WRA your wrapped too tight yes which means it impacts your circulation so CMS dysfunction right so what might they experience if it's too tight ofing in it numbness tealing absent sensation color change color change so they might get pale [Music] cold a joke but blue is also very very bad so as much as it is a joke people think that won't happen it can right so blue cold numb tingly I like to encourage my patients to be involved in like neurovascular aspect right because who can actually tell you if they're numb and tingly patient patient not you right who can tell you if they're super cold or they're changing and that that one foot is getting really really cold patient right the patient first right unless you're living there touching them which you're probably not you've got a few other patients probably on your roster right so make sure they know what to look out for and what to report because the sooner you intervene guys the better outcome for that extremity and it all kind of goes back to a lot of that CMS e elevation where are we elevating to the level of the heart and it has to do again with perfusion right if you want to maintain that profusion you should not be extending above the level of heart okay guys so everybody put their arm up in the air okay now leave it there for 20 minutes just kidding but what happens if you were to leave it there for even a minute or two that'll hurt right what starts ABB it gets really heavy and then what happens to your hand tingly it gets a little numb maybe a little tingly your fingers get really cool right you'll probably start to see the color start to shift a little bit too because your body is having too much trouble right extending and getting that blood flow up higher right which is why we don't want to go above the level of heart you want to stay at the level of the heart where the heart can still actively peruse I broke my arm a few years ago um it's quite the adventure and I was not casted or splinted because I would lose all range of motion because ultimately I broke like the radial head so my elbow right so casting or splinting in that position I literally would have never been able to do this again right so they prescribed to me what they call dangle therapy which is exactly what it sounds like let it just dangle right now I was able to get about 95% and possibly even more but I have not gone back to the orthopedist in my defense though it's just long term it would take six months for full swelling to go down and he said I didn't have to go back okay so not condoning not falling up but my point is is that like when it came to pain the pain wasn't the bone for me it had everything to do with the swelling and in this position guys what do you think happens swells it just swells with all that dependent fluid so since I wasn't able to really elevate it or do range of motion at the very beginning I would slink down in my desk chair and put my hand on my desk at the exact level of my heart to reduce the swelling right and kind of get that relief while at the same time doing what they considered kind of that dangle therapy and keeping it straight right so anything higher super uncomfortable right now did it take away some of that swelling yes but instantly I got cold right I was already fairly numb to begin with but that numbness did not go away at the exact level of my heart I felt complete relief the swelling would kind of go down I'd still stay profused right my hand was still nice and warm everything was good right so you don't want above the heart you want at the level of the heart right to maintain that profusion C so CMS we already said it at the beginning but it stands for circulation sensation and movement circulation movement right sensation all three of those Encompass the five PS five to six PS which include pain pain power pulselessness pulselessness paresthesia paralysis pcmia right sorry you guys all said them all but differently right so it's okay but we want to check all of these like I mentioned in pre-lecture questions right to ensure that we're adequately adequately profused we should be doing that after an injury so that should be one of the first checks we do anytime we intervene so if you decide to use an Ace bandage or a brace we should be rechecking CMS right as we move into dislocations and we move into fractures right anytime we cast or we splint or we reduce a joint right we need to check CMS and then we need to do it frequently thereafter right in that immediate process as well because complications like compartment syndrome right might cause that alteration and profusion right the swelling right within that fascia or the cast can lead to that kind of the same compartment like syndrome right so we have to be on the lookout it's a repetitive assessment and you can't just do it on your affected extremity you have to compare to the opposite on affected limb how many of you have very cold feet in the winter right now if you came in and told me you twisted your ankle but you know what you walked in your mailbox Barefoot I don't know why you would do that but you know whatever you did it right you're super super cold you twist your ankle and I'm seeing you not 25 minutes later how many of you would say your feet are still ice cold probably good chance right but if I only looked at your one injured extremity what do you think I'm going to think with your cold foot that you have that you have some type of circulation problem but if I compare it to your other foot that is equally cold right do I have a different Pathway to consider right which case then we're probably going to talk about both outside in the winter right so we have to compare to the unaffected side the other thing to remember with circulation is that a few factors don't really apply one Skin Integrity does having a contusion or having a skin tear impact circulation should tell me if you're looking at somebody and they've got a cut does that tell you that they're being profused or they're not being perused yeah they're bleeding what not distally though are you profusing if you're bleeding everything out no no check rep pulses pulse like pulses and cap refill dist is that's really important about like circulation right we don't necessarily need to say oh you've got a skin tear that's what impairs your skin like your your circul it's all about the distal check right so past that injury site so my skin integrity isn't going to tell me anything about circulation right you have to still check distill right what's the temperature of the skin what's the color right is there good pulses good brisk cap rebuil right distal the presence of your skin integrity does not impact CMS the other thing that we would never want to do is active range of motion to the affected extremity or injury sight right no active range of motion so if you twisted that ankle again going out to your mailbox right the last thing you should do is pick up that ankle and be like does it rotate all the way around right because what are you going to do to your patient do more damage potentially do more damage right and hurt them worse so when we think about CS it's distal right so now this is that can you wiggle your toes can you wiggle your fingers right that's the movement I want not can you take your broken bones can you take your dislocated joints and move them all over distally what are you capable of doing so make sure we're assessing that distal aspect okay next up is dis joint dislocations guys what can dislocate shoulders shoulders hips hips fingers knees elbows right anywhere where there is a ball and a socket right this is an emergency anyone know why circulation yeah so the dislocation can actually impair your circulatory function right so if you look at like this x-ray right consider if your your veins and your arteries were kind of right underneath there look at that socket and look at that joint could you and would you potentially be pinching off circulation right yeah and that's where a big risk factor of like avascular necrosis comes from right is that that pinched off circulation or nerve damage equally not good so ideally we like to reduce these things in under 2 hours to ensure that we have good profusion how do people speically present with dislocations pain ability to move it limited range of motion to no range of motion in that area shortening or lengthening and I say both because it ultimately depends on how you're dislocated if you like dislocate like anteriorly right it might kind of be shorten but if you dislocate posteriorly sometimes that extremity is a little bit longer right so it just depends on kind of which way you dislocate change the joint Contour change in the joint Contour right everybody feel your own shoulder right now let me then move that shoulder nice and Round right no real divots there now imagine you were palpating this shoulder what do you think you're going to feel feel like all of a sudden this kind of like slope off with this divot before you get to that kind of rounded joint area right that kind of ball area so that change or that divot what do you think we do before we treat them to diagnosis fully xray x-ray yeah but they should because it's twofold not only will it confirm the dislocation but it'll also rule out fracture I don't want to be resetting uh dislocation if there a fracture present correct because my treatment plan right cannot occur if there's a fracture if you were fractured below and I pulled let's say that arm to kind of get you back out back into the joint there but you were actually fractured what do you think I'm really pulling on the broken bone the broken bone right and am I even impacting the The Joint aspect probably not probably not am I doing more damage absolutely yes well though probably be is there but there's also a fracture right so you can still reset with a fracture that's depending on where the fracture is and no typically we surgically now need to repair it because you can't pull and reduce manually so once we have this x-ray we confirm there's no fractures then we look to do kind of that reduction that manual reduction we often do it through a process called like Conscious Sedation anyone know what that entails like not a full they're not putting you out fully so um Conscious Sedation is essentially sedation where you still can maintain your own Airway so you don't require definitive Airway this is to reset it so yep to reduce it Conscious Sedation can be used for more things than that but for this sake right they're able to kind of reduce it using medications like propol or pain medications and like light tives like morphine and valume right or a combination and ultimately what it does is it puts the body in just enough of a relaxed state that when we are manually pulling that traction guide your body doesn't naturally kind of Bear Down and fight it right and it gets it back in that appropriate joint what do you think your role is in Conscious Sedation what about before that consent there we go consent we need consent to do it right and your role in consent is again witness and verifying its presence right that we do need IV access typically for the medications now in the state of kinetic gift you cannot legally push propol without a secured Airway so actually the doctor has to do that medication administration the other medications like pain medicines and sedatives the nurse actually can push right but proall the nurse and kinetic it couldn't so we would need to be there for met Administration and then I heard some of the other things Vital Signs what else are you monitorings ABCs right Airway breathing any change in that circulation and then after the procedure we actually want to immobilize The Joint because naturally with injury you start to swell and in this case your muscles are a little bit kind of weakened from that dislocation and that joint sight and we want that joint to kind of rest for a few days while those muscles tighten back up to keep that joint in place so got two videos show you huh not everyone's Jam I'll agree it's the I have trouble with the well then turn away we're going to look at a so so in your in your car accident what did you hit with your knee was it a was it a head-on accident or pardon hit the back of got it so he hit the back so his KNE probably launched right into the dashboard ouch Y and see our x-ray that is not where we should be still pretty pain not appropriately what are we doing here unlik okay proed pis we want to make sure there's no additional injuries because again pulling even on the pelvis here could cause more damage what are we doing there to the right checking the opposite here comparing so somebody was checking the other PSE but on your left we started with sensation look we're comparing now so how much use okay now they're kind of doing the conscious station one per kilo what I heard sometimes they start lower those but so slow push it's actually not a slow push consider it looks slower but right right right it's not a two minute push so guys as I administer this medicine it does have a nice short halflife but they want to make sure again you're relaxed enough usually you're kind of out of it maybe you Mumble a little bit but you're usually not super responsive he's got pain medicines already on board too so like they're assessing right they're determining if he's relaxed look at are you awake are you awake you awake no I think he's out so what you doing just pushing onal cond oh [Music] God that wasn't that bad that bad everybody's just imagining being that person though he can't feel it yeah he can't feel it he can't feel it I didn't see any I didn't see any either he he did moan but if I let this continue to play out he'll ask you oh is it done yet at some point like he literally doesn't remember so kind of just like just body just yeah he's uncomfortable so it's just maybe not to the moment but just right do they follow up with another x-ray just to make sure so they actually mentioned following up with an x-ray they are immobilizing now AAL brachial like index is something that doctors do it's another test for perfusion and they compare it in both leg so that was what the blood pressure cup was just doing so so your Technique and reduction uh so we you just kind of stabilize the fal conds with this this G sub traction while pulling interly and it essenti came back red okay yeah it wor it worked nice pretty cool thank you for parp now there we go guess what they're checking again PES guess what they're going to continue to do they're continue we kind of lose the video of it but should be a full CMS check right I'm gonna kind of stop it here he just explains his procedure again right but kind of interesting yeah right the next video guys I'm going to fast word it's really training video for different techniques but I really just want to kind of show you the process looking for the most comfortable stylish easiest pants around try new Sketchers slip in pants just slip in and experience large scen that's there we go I don't know why I won't get the big screen gra after that you notice your shoulder was hurting so here's one view of her shoulder on the look like here's her second view of her shoulder so she got pain medicine and a light sedative and now here's where I'm going to fast forward you don't need to know the exact technique cuz who's going to do that the doctor take a peek you're going to see two people are stabilizing her in that arm right now watch when he rotates just pops back in no watch him rotate that ar oh my God why is do it's not in a joint it's just freely moving it's not in its joint right now our a little men student in Gray there is actually well he's not little sorry not but like he's watching The Joint itself and he's actually kind of got his hands right there to see if he can feel it shift in right that was worse than the knee yeah mind you she's actually Wide Awake I didn't feel anything yeah she so what they treat yeah oh God what is this must you must have clicked on an ad just a little quick shopping guess um okay anyway they're going to do a post stopy though cuz like she said I don't feel anything shift in right so they're looking and palpating but is there a chance she's still partially dislocated yeah yeah so like a postop film will kind of confirm or deny say that one more time speech space Oh space reduction it's just kind of part of that technique there's different approaches to kind of how you can reduce it yeah um okay so anyway two just kind of quick videos to give you an idea of what that means he went like yep like yep kind of walked it back and then rotated mhm that was nasty yeah it's really not as bad as you think I think hips are probably the worst I mean you see in movies or something they like run up against the wall and just pop back in themselves real quick see that you do guys if you're dislocate enough times in a year they actually will surgically intervene because that means your joint is so loose that it's genely not holding your joint in place and again that's from repetitive kind of dislocations but people do and like the morning class said like oh I've see people do it without meds and just kind of pull twist right kids are definitely a little bit more pliable so usually that's a population sometimes we able to do that more frequently without meds but more often than not guys you need to relax and how many of you would relax if somebody starts doing that to your dislocated joint right not many so this would be the nicer Avenue although I have met one or two people that dislocate and if they can't pop themselves in without experts which is again bad idea not promoted right um they will come in and they just ask and they said oh if you just like put my arm behind my back it will pop back like they just know cuz they dislocate enough but again not recommended right when I was pregnant my locating mhm I just learned to pop it back in yeah but there's a chance you do it wrong or you impin something and there like so it's not the recommended option but okay guys moving on to fractures fractures are ultimately defined as a break in the continuity of the bone right now I'm not asking you to ever done diagnose the exact fracture type but we should recognize and that the image kind of alludes to it right that there are multiple ways to truly fracture a bone right in different manners all usually from from different injuries right some are are Force driven right compression driven um it just kind of depends on exactly how how they are injured so we don't need to be able to identify so testing purposes than you for picking up on what I'm putting down but no we're not doctors here right but we should again recognize that they do fracture in different ways which means they present differently right your compression is going to look different than than you know you're computed right like you're kind of see those differences so how do they present what do you see in your patients pain crepitus pain deformity deformities loss of function shortening reidus muscle spasms and swelling discoloration fracture blisters are usually in like areas of flexion so like your ankle is a common site for something like that where the skin literally blisters yeah and like certain ones you want to be able to identify right for like signs of abuse like um spiral Spiral would definitely be signs of abuse but like you would again be interpreting an x-ray right so it wouldn't be okay wouldn't be you but you would be like looking out for signs of abuse for sure yeah right so again the presentation might vary based on exactly how they're fractured like you might not obviously see an obvious deformity with somebody with a compression fracture in their spine right but I probably will with a commuted fracture right how do we manage them what do you think we do first what do you think we do first what do you think we do first pain what CMS checks CMS check CMS check remember I say it over and over again inter now you guys are not wrong guys IM mobilization should be a very close second but I need to determine right that that perfusion I need to do my CMS check because if there is a gross abnormality do you think I'm immobilizing them in that position nope no what do you think the doctor needs to do Sate them and and set it maybe or they need that manual retraction right to realign and and again restore profusion so see Ms first right immobilization second that immobilization may require the reduction of the bones to take them from spell everything right I'm broken and fractured like this guys that reduction needs to kind of pull out and realign them right before I immobilize right and then once I do that guess what I'm going to do pain management guess what I'm going to do um CMS CMS CMS again yes now pain management definitely should be something you are considering especially if you need to do reduction and and manipulation of these fracture sites so please don't discredit that in any way what are some of our immobilizing devices for fractures sling slings splints casts casting buddy tape for your digits right in toes or a baseball splant which kind of looks like a little mini person it's just kind of like the head up top right which is the length of the finger and then it's usually got two kind of like arms and two almost feet right it almost looks like again a little mini person that just hugs your finger right and those arms and those legs kind of pinch again kind of creating that immobilization it's usually padded what about your neck C collar M so we've got a few options depending on again which part of you is fractured if this was an open fracture we need to approach it a little differently right I don't actually want to cover this up and splint it entirely because guess what's inside bacteria right forign Pro like debris things like that the last thing I want to do is kind of seal that up into you because again what are you at risk for osteitis osteomylitis so typically we we deal with open fractures surgically and we'll flip aide and cover that a little bit more in the meantime you should still cover it but you're not doing like a formal dressing we just want to take a sterile covering over that site so we don't introduce more debris and bacteria into that site but it's not formal like it's not a full final dressing open fractures typically also get antibiotics prophylactically I'm sorry my mom keeps calling I'm just to sit make sure she's okays am so prophylactic antibiotics guys for open fractures to prevent oste to prevent osteitis this is actually a technique that orthop itics use for routine Orthopedic procedures in that pre-operative phase guys they will actually administer antibiotics because that direct contact even in a routine surgery increases your risk of oste osteomylitis infection so antibiotics are usually done um nationally I do believe the goal is within 2 hours of injury right most internal facilities will have shorter goals to ensure compliance right but again you want to minimize that risk right so think antibiotics we should also be concerned about that's okay circulation is there a risk for Hemorrhage yes anywhere specifically you think have a greater risk fracture helic fracture why order runs that way your arteries that's your blood oh femur femur right your femoral artery right so that femoral artery to your point right runs right through your kind of pelvic binder like right there your pelvic kind of book there and down and right along our femoral or femural right so think about that if I fracture my femur could I Nick my femoral artery yeah I have an open book pelvic fracture am I likely to potentially rupture part of my femoral artery right so there's a RIS for Hemorrhage where when do you think I will notice this risk for Hemorrhage right away well here's the deal only if it's an open fracture will it'll be immediate right there' be blood everywhere right see signs of internal bleeding Vital Signs right so that would be one big indication for hypmic shock right tachicardia hypotension systemic cool clammy cold skin diminished pulses right but it's going to be systemic it's not just distal to my fracture site right so again that's major blood loss from that artery do I need to intervene with that before I manage a fracture yes yeah mhm how am I going to intervene get blood fluids fluid blood if they're losing blood guys what do they need blood transion blood right so more often than not this becomes a surgical emergency again right and they need blood in an hour another thing to kind of be concerned about is as we age hemo concentration so our blood tends to kind of thicken a little bit it's not the same as that polycythemia vera and sludgy but it still is kind of more concentrated which puts them at a much higher risk for plots plots right so with our aging population something else to be on the lookout for is cloths we tend to treat them just like we treat any other cloth so what meds might we use War a Hein right low molecular heprin or maybe an anti-coagulant right stronger depending on the knees right can I do exercises like the foot pump right and kind of flex and and extend right can I squeeze my muscles and my calf muscles right so I can promote exercises like that I'm never again going to take that whole extremity and do range of motion right that's a o but I can do those low intensity kind of exercises but what's really going to help with that hemo concentration is just IV fluids right just kind of a 100 MLS an hour or 75 MLS an hour infusion right kind of dilute and kind of change that hemo concentration so we got a few Focus points neurovascular checks immobilization with or without reduction manage or assess and manage for hypmic shock right and prevention of cloths with our aging population we've got a few things to consider when we think about those surgical interventions we've got a few things right if it's for an open fracture part of that focus is that debed Min that water wash out of debris and bacteria from the sight they might even use antibiotics kind of as part of that wash out to reduce that risk of osteitis but the other portion of it is surgical reduction and immobilization so they might need internal or external fixation devices pins screws rods bars it's all going to be surgically completed what do you think you do postoperatively CMS checks CMS checks right what else ABCs ABCs because in that postop period right we still have that concern for Airway breathing ventilation problems monitor for signs of infection at like the pin s sites we want to look at the actual surgical sites if there are pins involved we want to look at the pin sites as well pain management we're going to look at a few more of those up close shortly too so to kind of recap right we want to know what the treatment regimen is right we want to know what the plan is are we able to at the bedside do a reduction and immobilization do they require surgery or wound breed we should have a good idea of our pain regimen pain control again should it be opioids or nonopioids both maybe combat combo right it could be one it could be two right it could be both right what about non-pharmacologic all them right don't forget about those options we want to improve our physical Mobility so although most fractures are non weightbearing to start we do not want to decondition our additional muscles so we want to encourage activity with the other muscles so consider if they broke their femur using the overhead trapeze on the bed to still move and reposition their upper body right and maintain that strength okay we want to maintain neurovascular checks again we're going to be routinely doing this engage that patient have them tell you if they feel something funny we want to restore function over time who do you think is going to help with that PT yeah OT PT right over time is going to be a slow ramp up back to normal activity levels for that affected extremity we want to look and monitor for complications which has its own dedicated slide in a second some other complications that can ultimately become bigger complications are the additional injuries that are not so severe think about somebody that crashed their motorcycle right and they got dragged across the road right and now they've got Road Rash right but they fractured that leg too what's your focus properly what are you most concerned about fracture to start fracture but then you know infection risk of other areas and yeah issues yeah so here's the deal you're concerned about the fracture they have to immobilize it right they have to do that well what happened to all the abrasions yeah right did we wash it out do we put antibiotic ointments on it or something along those lines because if I wrap it up and forget about it what's your friend have an infection probably a soft tissue injury turn to infection which will then extend into the Zone maybe right so we don't want to be so distracted with the big fracture that we don't forget like that we're we do forget about some of those smaller injuries like abrasions right associated with that trauma I had a gentleman actually that crash his motorcycle and he did not have road rash but he had an opening and it's like this big I that's it it looks actually really clean from the outside of the world right there wasn't really any major bleeding nothing was really you know stuck to the outside he ultimately lost his leg from L my li right it's a tough and stubborn thing all it took was that little puncture right to open him up to that punct are dangerous they are this is why we talk about it so excessively right okay so complications we talked about most of these actually already right fat embolism again is usually from the release of fat globular into the bloodstream that includes the vascular kind of structures most common is from long bones usually impacts like the lungs right and cuts off oxygenation to like the lungs or the brain how do these guys present disa confused confused disia cough is very common tartic peal rash wheezing anxiety anxiety that kind of feeling of air hunger that they're not getting enough Air Guys there's not much you can do about this I said there's no magical kind of like anti-coagulant it's not blood you just treat the symptoms we treat the symptoms and we really focus on ventilation support so they might get intubated so we can kind of control that ventilation we can try steroids to kind of treat that inflammation but there is no magical kind of cure if you will so it can be lifethreatening it is most common 12 to 72 hours after injury so we have a window right 12 to 72 hours after injury we talked earlier about your delayed Union your Mal Union and your non union right delayed slow that's still occurring right Mal Union where it's physically misaligned or non-un where those two ends physically are not fusing back together and core mob bidities like malnourishment diabetes can cause some of those delayed unions Mal Union or non-union can be from inappropriate immobilization or lack thereof delayed Union obviously we want to support as much as possible but your other two might require surgical interventions right and the correction of that immobilization Venus Brom rbo Emi our cloths right again what can we doation early immobilization if appropriate right what else medication therapy like your heprin what else range motion on the other range of motion on the other Limbs and on the affected limb what can I do foot kind of pumps right the muscle contractions right where I'm not again range of motioning that actual extremity but I'm doing those low intensity exercises STDs for my aging population what might they need for that hemo concentration fluids fluids DIC again we talked about last week mhm right micr cloth all those claic factors are now utilized so now I start to Hemorrhage I want to intervene the second I can see right that the clotting factors are utilized so platelet counts PT inrs want to intervene as soon as possible a vascular necrosis is that kind of impaired or compromised for Fusion or nerve impingement as well in at the same time no profusion to the Bone means the bone death of the bone I need to restore it as soon as possible or there's risk for amputation amputation the reaction to some of your internal and external fixation devices again hopefully identified prior to surgery and we're not utilizing materials we have known allergies to but lower likelihood most are relatively safe in this day and age but if your body recognizes it as foreign it will start to react right how do I fix that REM I remove it right and I place other devices casting do you guys have a role in casting yeah yeah sometimes the nurses can actually physically perform the casting after additional training not all facilities do it and it's usually more of your simple fractures not not things that require extensive reduction and and Alignment but you might still have an active role on those cases where you assist so the actual application guys there's usually two parts to it one you want to hold that reduction kind of position so usually somebody's helping to kind of keep that that extremity aligned properly or twoo you might help with kind of the rolling and the actual firming up of the cast pley glass and fiberglass guys can take about 15 or so minutes to do the initial drying process but almost 24 full hours if not longer to 20 48 Hours sometimes to fully fully dry so in that first 15 minutes like if you reduce like and you and you let go of that traction or we misshape it guys it's going to permanently end up drying like that so that that 10 15 minutes is pretty critical to make sure that we're keeping everything aligned properly use the palm of your hands yes so part of that application does require open Palms because if you were to squeeze it and put your fingers into it guess what it's going to do MTH it's going to dry with those fingerprints and you're going to have a misshaped right kind of pressurized coins within your cast and that's bad so we want to kind of make sure that we we are assisting in the proper way um there we go it's a video it's a training one this person is not fractured so they don't hold traction very well and like that reduction very well welcome to the tutorial on shortarm cast application it goes through some of the supplies required AG group and the cast application to the skin proximately to maintain reduction in the cast the easiest way to maintain owner deviation is to have your assistant or finger traps hold the thumb and then maintain reduction on the limb having an assistant or finger traps holding the reduction is important you will then apply the stock and edine here you want to protect the transition zones where fingers come out and the upper arm comes out of the cast with three layers of padding the cast material should come to the knuckles the cotton or Weil should be layered on distantly approximately in such a manner has to not create wrinkles in the material this will require you to tear the material as you turn Corners the cast padding should not be thick especially at the fracture side because the padding will compress proportionate to the amount applied and if too much is applied at the fracture site the padding will compress enough to lose reduction of the fracture the cast padding should typically be two layers thick proximately the cast should be longer on the owner side than the radial side your goal is to get at the tip of the lacron but leave the clearance in the anticubital space so that the child can Flex their elbow to accomplish this goal the cast should have an oblique finish typically even more oblique than what is ultimately shown on this particular cast an additional piece of cotton can be applied at the distal and proximal borders of the cast to provide that third layer of padding at those transition zones or the edges of the cast as mentioned once a thin layer of padding has been placed you can apply the fiberglass the fiberglass should be briefly dunked in the water and can be shaken off lightly but should not be squeezed the fiberglass is rolled On Loosely and not stretched on take care not to create Shar edges or creases when applying the fiberglass I mean that looks creased at the top but I would ask that agree with that yeah he's also not holding much in the actual fraction aspect of the you want to maintain the pattern at the proximal end of the cast again trying to get the cast to the tip of the elron while being short enough in the anticubital fausa to allow the child to flex their elbow you can cut partway through the fiberglass to allow it to fit through the web space better if you do this be sure to fold the sharp edges of the fiberglass inward the child's skin once the first layer of fiberglass has been applied the edges of the stock and Ed can be folded back over the cast concealing the edges of the fiberglass and preventing the child from picking out the padding that's just meant to protect it guys fiberglass is very sharp so you don't want to damage the Skin Integrity okay we're going to fast forward because you all get the concept of it wrapping around the arm is that another layer of the border of the cast should be flat reflecting the shape of the the radial side of the cast should be convex reflecting the shape of that bone so what he's ultimately doing now is shaping it appropriately to ensure that it it's holding the right Port based on that fracture get the open Palms use your assistant to help apply the 3point mold to maintain reduction of the fracture sight your assistant should hold the thumb definitely using his fingers apply dorsal pressure to the proximal portion of the cast you will apply dorsal pressure at the distal end of the cast and at the fracture site with one hand and Boler pressure just proximal to the fracture with the other alternate between three point mold the osus mold and flattening the Border until the cast is hardened of the hand continuing to describe it but anatomically again who's responsible for that positioning like the Physicians right we're asked to kind of hold an assist more than anything right sometimes again smooth it if they need that second pair of hands and the area is large right um but the point kind of to that video is that like there's a process there right and if we don't hold traction the right way will we misalign them right so we have to be in the right position so usually from my perspective we don't cast ourselves Ortho team kind of comes down but like I've assisted with the wrapping because I'm not strong enough to hold enough traction to have it in the right space like depending on the the the severity of the fracture sometimes totally capable but depending on the severity it has to be in the right spot you can't have partial traction and then splint them in that right so we want to make sure that you're you're effectively doing your rooll how do we care for this cast we know it takes about 15 minutes for that initial drying up to you know 48 hours if not slightly longer for full drying so how do we care for it what instructions are you providing this person patient want sub water get it wet yeah we can't get it wet because guess what happens to the fiberglass or the plaster it softens it's now moldable right which means the impact can like ultimately lead to that misalignment again right that improper immobilization what else don't stick anything in it don't stick anything in it has anyone ever out a cast how fun are they not really how itchy are they they say use a blow dryer on a cool setting they say a blow dryer on a cool setting should help alleviate some of that itching I make zero promises but what you can't do is put things down it right because what is a likely that you scratch your skin it's a likelihood that you now have a well stuck too but now you have a wound there that you can't see you can't clean right you can't clean it for those of you that had a cast how did that smell comeing off because it's a dark damp sweat filled area right so think about that risk for that soft tissue injury to not be infected and then spread to the bone bone right so we want to make sure that that we're we're preventing those types of issues when it comes to like the removal of the cast we want to have some precautions in place as well so for those that had it removed did they have a saw going right did it get really warm right and did it create debris right so all things that we should warn and prepare our patients and ourselves for so we should all be wearing eye protection in the room and masks to prevent the inhalation right of the the debris and we should warn our patient that it usually gets warm from that saw working it's not supposed to be warm enough and it's not enough heat to like burn the patient but nonetheless we should pause and kind of rest if it is getting too warm there's usually a guard underneath the blade so there should be zero risk to truly puncture the patient but again that's a nice educational point because if you showed up and had a saw next to me I'd probably be like no right yeah Subs that just vibrate and there's really like no yeah rotation yeah there are multiple different variations it depends on what you have but most of them have it is ultimately even the vibration is really kind of like a rotation too it's just not as aggressive as something like the bigger ones um but nonetheless they still cause debris and kind of warm due to that process right so we want to kind of make sure that we are properly preparing our patients what do you think that extremity looks like when you come out of a cast somebody said shriveled always said not far off though right it's usually shrunken in a deconditioned muscle atrophy right there's that muscle atrophy so it does look skinnier it looks smaller um what did somebody else say disced discolored because guess what it lacked any type of sunlight right so usually there is that loss of kind of color they're a little paler right now what are you to educate your patient can they just go and start deadlifting their 300 lbs like they used to no he's into it he's into it yeah they have to kind of start with PT range of motion and work up that strength because again that muscle as much as that bone right needs to kind of recondition to accept that whole activity level which does kind of take care of a handful here of our cast complications one pressure ulcers those fingerprint marks right or again if that cast is not super smooth we can have pressure ulcers well no different than scratching and kind of causing that wound right bacteria can extend into the to the actual um bone right OST my lus now if there's a suspected kind of pressure injury they are able to kind of do like a cast window where they cut out a portion of the cast and kind of relieve that pressure and then reinforce it properly or maybe they start all over depending on that extent but that's a problem right and again the proper application will prevent that disuse syndrome is kind of that skinny right muscle right that deconditioned muscle after that cast strength and you want strengthening exercises compartment syndrome is our big one and our big big problem compartment syndrome in itself can be acute chronic or from a crush in your Q is usually from trauma and fractures or casting chronic is from overuse I had a gentleman come into the ear when he was act like cutting wood with an axe for like hours right that repetitive overuse well that friction against the fascia caused swelling right so outwardly he looks very fine right and he kept coming in and just saying like oh my arm is killing me my arm is killing me right and they tried to give him pain medicine and discharge and I mean threw a little bit of hisy f but they finally got him discharged they came back not an hour or to later going like you're not listening like like this arm is like like it it's so incredibly painful so they kind of like appeased him and said fine Ortho can come see you but there's like no fracture like you're okay well guess what Oro came and did fomy before that CMS checks CMS checks and guess what was delayed cap refill right he was cool like he was showing signs of full compartment syndrome right he ultimately was in an O very shortly after for a fasciotomy right so compartment syndrome is not something that necessarily like is controlled well with even opioids it's usually immense pain and you don't have outward huge signs you see alterations in CMS right and we want to see them as soon as possible right so the second they start to show or say and state like I've got numbness I've got tingling their skin color and temperature are starting to shift they're getting cool right their cap refill is getting delayed we need to notify who provider immediately right we need to call the sergeant immediately right now if there's a cast in place guess what we do the cast comes off it comes off right but if it's not just the cast right we might have to ultimately do a fasciotomy so what the ortho team has is they have this kind of measuring device kind of almost looks like a meat thermometer sorry to give you the graphic view but they literally pierce it right into the fascia and they look for readings it's measured in millimeters per Mercury anything under 10 totally normal anything over 10 we are we've got compartment syndrome anything over 25 requires a fasciotomy i so they're those need to know numbers you should know what's the test end yeah what's that thermometer called or oh gosh thing meat thermometer I'm just going toite that what it looks like let see if I wrote it down over 25 you said under 10 is normal under 10 is normal yep over 10 is compartment syndrome yep it requires f 25 or more over 25 is fasciotomy I didn't write down the full name of it guys that's all right I'll remember but again it measures that pressure right and we want to make sure that we are appropriately treating so the third option is is a crush injury and usually it's from that release of that pressure and then the Sudden Rush of fluids right including some of our myoglobulin right creatinin enzymes that can ultimately not only cause compartment syndrome but can even damage our kidneys and lead to things like rabdom myosis it just depends on again kind of like what the cause is the same thing is happening in all of these a lack of profusion we have to correct that sorry Striker is is the device trer sounds like maybe the brand the brand I want to say something borrow meter but I be wrong on that I'll look it up stic pressure monitor yeah I'll look it up while you guys take your quiz okay so long story short though late ominous signs are pulselessness and power at that point guys there was Zero profusion right we need to intervene we talked a lot about kind of traction and kind of reducing and aligning those those bones there are a few different ways to do it based on the parures we have skin or we actually have skeletal traction devices skin is exterior nothing is internally placed on the patient it usually can be something like Buck traction or even like a hair traction splint and they work similarly but in fck traction like the image is showing you there is almost a knee immobilizer like device so it goes kind of up to the thigh down through that calf and at the bottom of that is what they call an ankle Stirrup that ankle Stirrup then hooks up to this thin little wire and draped on the edge of that bed is now a weight right and it's literally weighted so that ankle is being pulled by that weight right now nothing again is inter which means your skin should be intact right you need to monitor for that though because is there still pressure if something is being kind of pulled so even with foam could I have skin breakdown yes right or damage right so part of our job and monitoring this type of traction is that it's appropriately placed there's no skin breakdown and make sure the weight's always freeh hanging and make sure that the weight is not only freeh hanging but level right let's say the wire started to fray what do you think is going to start to happen tilt right it starts to tilt and now there's more pressure on one half of you than the other half right so you want to make sure all of that is appropriately functioning including your patient your patient has to maintain the right position too they can't get all cocky in the bed right and kind of curl up in a ball because that would miss a lie this fraction so we want to kind of not only check your patient's positioning but the actual device itself for proper functioning skeletal traction whether you have the external fixator which is like the the picture with the leg right with the pins for or internal which is not necessarily externally seen But screws wires plates rods things like that they hold a different volume kind of pressured and weight they're just internally kind of structured now there is skin alteration here so they're at risk for infection right infection osteitis outside of the fact that these devices are screwed in or nailed in to their physical bone right so not only is that direct contact but soft tissue too we need to ensure that we are monitoring that site and assessing that site and caring for that site appropriately so when we think of that traction our goals are again effective appropriate traction so monitoring the device right maintaining that appropriate position of the patient preventing skin breakdown and then site care specifically the pin site if this is an external fixator now this video you're more than welcome to play it back in its normal speed but I am going to fast forward a little bit she's a little uh slow as she talks I would highly recommend pain management with this and you'll kind of see why in a second use your own usual shampoo or shower gel and give the limb and frame a good clean there it is okay so kind of goes through what the device is pass through the skin and sometimes the muscles to connect the external fixator to the Bone sometimes wires are used with pins or instead of pins to hold the bone pieces directly into that bone there right so we're going to jump into the steps to actually clean sterile water or other cleansing solution recommended by your surgeon disposable cups sterile Gau dressing 5 cm by 5 cm and 10 cm by 10 cm sterile cotton swaps St bag for Waste Disposal paper okay step two hand washing everybody knows how to wash their hands correct okay but is reserved for you use a clean paper towel to dry your hands and throw it away after use don't touch anything else before starting the cleaning procedure such as your wheelchair crutches or dressings step three gently massage the skin around the pins with your fingertips make sure that the skin is free to move slightly this brings a drainage to the surface so that it may be cleaned away here's where pain management plays a huge part pour the sterile into the Disposable cup then dip a sterile cotton swab in the sterile water start directly at the pin sight and move the swab in a circular motion around the pin making the circle larger as you move away from the pin site remove any drainage or crust that may have formed now do not sorry that's okay I was told that you should not remove crust because it's almost a barrier you should because if there's like EXT dat underneath it you need to get that out so usually it's like kind of it's scabbed onto the pin so you're not ultimately cleaning you kind of want it freely not freely moving like there's a big gaping hole but it should be movable okay yeah so do redip the cotton swab why gross contamination gross right cross contamination everything's kind of ruined which is why they tell you multiple swabs right okay so we got that new cotton swab so now we show new cotton swab right our next step remember to use a new swap for each pin step six wrap sterile gors Loosely around the pin sight if there are raw edges of gour roll them inside so that no loose filaments get into your PIN sights place your fingers over the GW and gently press down on the skin around the pin sight after the first few days when the pin sights are dry G should not be used instead the pin sight should be left uncovered and exposed to the air step seven you must also take care of your external fixator the entire device should be cleaned using the cleansing solution 10 cm by 10 cm G guessing and cotton swabs take care not to move the different elements of the fixator detergents with fluide chloride bromide iodide or hydroxy ions must not be used afterwards dry the fixator thoroughly with a clean towel step eight place all materials used for cleaning into a bag for disposal wash and dry your hands thoroughly again your surgeon may allow you to shower with your external approx ex yes I know so we're going to make sure that we are essentially cleaning and following this procedure throughout that initial healing process they will eventually let you shower once that risk of infection is hopefully decreased right again you can totally listen to her talk longer if you'd like it fun okay so that's a little bit about your PIN care like I said pain management has anyone ever seen skin care done before done it I've done it too comfy for these poor patients right these are not only pushed into the bone but your skin naturally wants to heal and part of that healing is like attaching itself which is where that scabbing on that that pin ultimately occurs and we have to literally remove that and manipulate that so you're like literally kind of pushing into that every single day right it's not comfortable so we really want to take that super seriously and again premedicate so let's review your teen has been seen in the ER for suspected compartment syndrome following cast placement on his left arm the cast was placed after diagnosis of a left radial fracture what are the three types of compartment syndrome acute chronic and Crush acute chronic and Crush right what's the important areas of assessment to determine if compartment syndrome has occurred distal distal to the injury SK cool pale all the peas right the the the CMS right neurovascular assessment is our key here the risk of severe blood loss would be highest if an individual fractured which of the following bones Fe why the femur the Ary very vascular but it's actually just closest to that femoral artery in comparison to our other bones and our other arteries right true or false the nurse should assess most carefully for signs and symptoms of a fat embolism during the periods of 5 to 7 days after the fracture false false false what's my time frame 12 to 4 72 12 to 72 hours so [Applause] false your patient was recently had an arm cast applied which of the following assessment findings would signal the possible onset of compartment syndrome AB pulse d d onset onset so okay onet pain and decreased range of motion because that goes along with the pain on set which means early changes in neurovascular status right numbness tangling difficulty with range of motion right decrease range of motion what are my late signs absence of pulse right would be late in ominous so it's that one word that changes your whole answer we're going to read those questions very carefully a blink is a socked tissue injury produced by blunt force contusion contusion doesn't underline I'm sorry cess prophylaxis would be administered in the ER if the last booster was over five years five years five I thought it was 10 now so you're good for 10 but in this instance okay right yeah so Proaxis so which means that there was some type of injury in direct contact so like your nail gun we tend to booster you after five yeah in blank there's a flog Union of the fractured bone Mal Mal un Mal Union DIC is a systemic disorder that results in widespread blank and microthrombus Hemorrhage hemor Hemorrhage and which one come first CL body next we got a little case study you got Kyle Jay here he's a 17-year-old that was injured during a football game the doctor diagnoses him with a fractured left femur he's being admitted postoperatively to the ortho unit where you're working currently he's still undergoing surgery in which they're applying that intern fixation device upon admission to the unit describe your nursing assessment neurovascular okay pain the site the site the surgical site he's Posta anyone want to do ABC yeah right kind of monitor that Airway right breathing infection yep monitor those vitals for signs of infection which would be kind of part of two there what complication should you continuously be assessing for infection infection infection right signs of osteitis now based on his other surgeries right I heard it thatat embolism is a complication what else compart compartment syndrome huh AUM my litis sure compart compartment syndrome Maybe he is internally fixated so if they cast it over that or spint it over that allergic reaction to the stuff allergic reaction to the device what else from that page DBT yeah I heard you the do yeah DBT R your thrombus AAS necrosis DIC right all the things all the things on that one lovly slide yeah end of chapter an immediate postop period which measure would best prevent a DBT early ulation out of all of these early ulation right multivitamin ain't going to do anything for dbts right measuring eyes and O not going to help me with dbts lowering the legs below the level of the heart no not going to do anything for gbt prevention you have a 22-year-old man admitted to the Ed with a crush injury to the bilateral extremities he was pinned under a car for 3 hours he complains of extreme pain in the legs distal pulses are weak and her feet are Dusky your x-rays show no broken bones based on this data what interventions are most appropriate c c compartment syndrome see let's walk through it right so our friend was crushed he has no broken bones so it's all soft tissue well well it's mostly soft tissue he was crushed I have no extreme pain have nothing here telling me broken bones no broken bones but nothing that says his soft tissues were damaged right so he was currently just crushed okay he is distal pulses are weak and Dusky feet so anticipating a VQ scan for PE relevant no to legs no notifying the provider to prepare uh to set up skin traction why would I do traction nothing's broken right I only do traction to reduce fractures right not fractured and then preparing to give IB antibiotics why do I give IB antibiotics infections infection I don't have anything here that says he's got any open wounds right or soft tissue injuries right so I want to anticipate that fasciotomy so your same patient here becomes semiconscious and continues moaning with pain his blood pressure drops his pulse has increased what's the most lifethreatening immediate problem [Music] b b yeah no you're right okay just letting everybody else come to the same conclusion right sorry no that's okay you guys are all good right B hypovolemia think about it his blood pressure dropped his p inreased is increasing he's showing signs of hypovolemia right this does not mention respiratory complications right he had nothing broken so would he have a fat embolism right and as for dis rhythmia he is actually at risk for dysmas but not from hypo Calia but hyperia from Crush injuries next you've got Richard 23 experienced an open fracture of the left tibia major soft tissue damage to the lower legs and a bicycle accident surgical reduction and fixation of the tibia were performed with de breed of non-viable tissue and drain placement in the damaged soft tissue which finding by the nurse would most likely indicate the development of oste elevated ESR what other labs white blood cell and the CPR CRP right blood cells and C reactive protein good question you ready for your quiz I think so [Music] first