hello and welcome to chapter 32 orthopedic injuries of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the anatomy and physiology of the muscular skeletal system you will have learned the proper assessment for a suspected and obvious injury you will learn general and specific types of muscle skeletal injuries including fractures sprains and dislocations with associated signs and symptoms and emergency treatment including the use of splints and traction splits so let's get started the human body is well designed system in which form upright posture and movement are provided by the muscular skeletal system the system also protects vital internal organs of the body the musculoskeletal injuries are among the most common reasons why people seek medical attention muscular skeletal injuries are often easily identified because of pain swelling and deformity although musculoskeletal system injuries are rarely fatal they often result in short or long term disability do not focus solely on the musculoskeletal injury without first determining that life that no life-threatening injuries exist so let's talk about the anatomy and physiology of the muscular cell cell system so you have three types of muscles skeletal smooth and cardiac muscles skeletal muscles also called striated muscle because of the characteristic stripes attach to the bones and usually cross at at least one joint they're called voluntary muscles because it is under direct control of the voluntary system and the responding two commands that move specific body parts it makes up the largest portion of the body's muscle mass all skeletal muscles are supplied with arteries veins and nerves skeletal muscle tissue is directly attached to the bone by tendons nexus we're going to talk about smooth muscle and that's involuntary muscles and they perform much of the autonomic work of the body they're found in the walls of most tubular structures of the body and they contract and relax to control the movement of the contents within these structures and then there's cardiac muscle and it is specially adapted involuntary muscle with its own regulatory system all right so let's talk about the skeleton next the skeleton gives us our recognizable human form protects vital internal organs and allows us to move it's made up of approximately 206 bones the bones also produce red blood cells in the bone marrow and serve as a reservoir for important minerals and electrolytes the figure on this slide illustrates the human skeleton the skull is a solid volt like structure that surrounds and protects the brains then you have the thoracic cage which protects the heart lungs and great vessels then you have the lower ribs protect the liver and spleen the bony spinal canal encases and protects the spinal cord and the pectoral or shoulder girdle consists of two scapula and two clavicles the scapula which is the shoulder blade is a flat e triangular bone held to the rib cage by powerful muscles that buffer it against injuries the clavicle otherwise known as the collarbone is a slender s-shaped bone attached by ligaments to the sternum on one end and to the acronym process on the other end because the clavicle is slender and very exposed this bone is vulnerable to injury the figure on this slide shows the pectoral girdle in the anterior and posterior view the upper extremities extend from the shoulder to the fingertips and is composed of the upper arm which is the humerus elbow and forearm which is the radius and ulna it joins the shoulder girdle at the joint and then the humerus connects to the bones of the forearm to form a hinged elbow joint then you have the hand and it contains three sets of bones the wrist bones which are the carpals hand bones are the metacarpals and the single finger bones which are the phalanges okay then moving down you have the pelvis and it supports the body weight and protects the structures within the pelvis the bladder rectum and female reproductive organ pelvic girdle is three separate bones the ilium ischium and pubis and it's fused together to form the hip joint the lower extremities consist of bones of the thigh leg and foot the femur which is the thigh bone is long it's a powerful bone that it connects in a ball and socket joint to the pelvis and in a hinged joint to the knees the lower leg consists of two bones the tibia and phibia and then there's the foot the foot consists of three classes of bones you have the ankle joints which are the tarsals the foot bones which are the metatarsals and the toe bones which are the phalanges the bones of the skeletal system provide a framework to which the muscles and tendons are attached a joint is formed wherever two bones come into contact so joints are held together in a tough fibrous structure called a capsule which is supported and strengthened in certain key areas by bands of fibrous tissues called ligaments in moving joints the ends of bones are covered with a thin layer of cartilage known as articular cartilage joins are bathed and lubricated by synovial joints and joints allow circular motion such as the shoulder joint or hinge motion such as the elbow and knee or minimal motion such are such as the sterno clavicular joints or no motion such as sutures in the skull so let's talk about some muscular skeletal injuries first we need to talk about the mechanism of injury so significant force is generally required to cause fractures and dislocations and the force can be direct blows indirect forces twisting forces or high energy forces a significant mechanism of injury is not always necessary to fracture a bone a slight force can easily fracture a bone that is weakened by a tumor infection or osteoporosis suspects the pro presence of a fracture in an older patient who reports pain or has sustained a mild injury so let's talk about fractures first and fracture is a break in the continuity of the bone often occurring as a result of an external for force it's classified as either open or closed with an open fracture there is an external wound and it's caused either by a same blow that fractured the bone or by a broken bone and lacerating the skin you should treat any injury that breaks the skin as a possible open fracture complications of open fractures include increasing blood loss increased blood loss and a higher likelihood of an infection fractures are also described by either or whether the bone is moved from its normal position so a non-displaced fracture also known as a hairline fracture is a simple crack of the bone that may be difficult to distinguish from a sprain or contusion a displaced fracture produces an actual deformity or distortion of the limb by shortening rotating or angulating it so simple terms to describe particular types of fractures include green stick fracture oblique fracture pathologic fracture or incomplete fracture also there's the community fracture it's a fraction which the bone is broken into more than two fragments you could have the fracture and that's um a fracture that occurs in the growth section of the child's bone that may lead to growth abnormalities in that bone and then a green stick fracture and that's an incomplete fracture that passes only part part way through the shaft of the bone and then we talked about the incomplete that's a fracture that does not run completely through the bone an oblique is a fracture in which the bone is broken at an angle across the bone and then of course the pathologic that's a fracture of a weakened or diseased bone generally produced by minimal force the spiral and that's a fracture caused by twisting force causing an oblique fracture around the bone and through the bone and then a transverse that's a fracture that occurs straight across the bone suspect a fracture if one or more of the following signs and symptoms are present if you have a deformity or tenderness guarding or swelling bruising crepitus false motion exposed fragments pain or a locked joint okay we just talked about fractures now let's talk about some of the dislocations so a dislocation is a disruption of a joint in which the bone ends are no longer in contact supporting ligaments are often torn usually completely allowing the bone ends to separate completely from each other a fracture dislocation is a combination injury at the joint in which the joint is dislocated and there's also a fracture at the end of one or more of the bones sometimes a dislocated joint will spontaneously reduce or return to its normal position before your assessment you will be able to confirm the dislocation only by taking a patient's history a dislocation that does not spontaneously reduce is a serious problem commonly dislocated joints include fingers shoulders elbows and knees signs and symptoms of a dislocated joint are similar to those of a fracture so there's going to be marked deformity swelling pain that is aggravated by any attempt to move it tenderness on palpation virtually complete loss of a normal joint motion and we call this a locked joint or numbness or impaired circulation of the limb or digit okay we just talked about dislocations and fractures now let's talk about sprains so a sprain occurs when a joint is twisted or stretched beyond its normal range of motion the supporting capsular and ligaments are stretched or torn brains can be from they could range from mild to severe and the most vulnerable joints are the knees shoulders and ankles after the injury the alignment generally returns to a fairly normal position okay so signs and symptoms of spray sprains include guarding swelling and echomosis pain or instability of the joint and then there's a strain a strain is basically a pulled muscle and it's stretching or tearing of the muscle it causes pain swelling and bruising of the soft tissues in the area unlike a sprain no ligament or joint damage typically occurs often no deformity is present and only minor swelling is noted at the site of the injury most patients will have extreme point tenderness okay and then we're gonna talk about amputation so an amputation is an injury in which an extremity is completely severed from the body this injury can damage every aspect of the muscular skeletal system from bone to ligament to muscle so now let's talk about complications of these muscular skeletal injuries so orthopedic injuries can lead to numerous complications not just those involving the musculoskeletal system but also systematic changes or illness okay so the likelihood of a complication is often related to the strength of the force that caused the injury the injury's location and the patient's overall health to prevent contamination following an open fracture you should brush away any obvious debris on the skin surrounding an open fracture before applying a dressing do not enter or probe an open fractured site you can help reduce the risk of long-term disability by preventing further injury reducing the risk of wound infection and transporting patients to the appropriate medical facility assessing the severity of an injury so the golden period is critical not only for life but also for preserving limb viability in an extremity with anything less than complete circulation prolonged hypoperfusion can cause significant damage any suspected open fracture or vascular injury is considered a critical emergency remember that most injuries are not critical so now let's talk about the patient assessment of these muscular skeletal injuries always look at the big picture evaluating the overall complexity of the situation to determine and treat any life threats you must be able to distinguish mild injuries from severe injuries because some severe injuries may compromise neurovascular function which could threaten long-term function all right so let's get into it the scene size up scene safety of course is number one and try to identify the forces with the associated mechanism of injury standard precautions may be as simple as gloves but a mask and gown may be necessary consider the possibility that there may be hidden bleeding evaluate the need for law enforcement support advanced life support or additional ambulances okay so the mechanism of injury so we already said look for those indicators be alert for both primary and secondary injuries consider what injuries the mechanism of injuries would lead you to expect and then there's the primary assessment so focus on identifying and managing life threats and treating the patient according to his or her level of consciousness and the ex-abcs is always priority remember the x is that massive hemorrhaging or extinguination so checking for responsiveness using the avpu scale consider high flow oxygen via non-rebreather or a bvm to the patients whose level of consciousness is less than alert and oriented ask about the mechanism of injury if there is significant trauma or multi-body systems are affected the muscular skeletal injuries may be the lower priority fractures and sprains usually do not create airway and breathing problems focus on determining whether the patient has a pulse has adequate perfusion or is bleeding if the skin is pale cool or clammy the capillary refill time is slow treat your patient for shock immediately maintain a normal body temperature and stabilize injuries in extremities prior to moving the patient and then there's your transport decision so if the patient you are treating has an airway or breathing problem or significant bleeding provide rapid transport to the nearest hospital for treatment a patient who has significant mechanism of injury but whose condition appears otherwise stable should also be transported promptly when a decision for rapid transport is made you can use a backboard as a splinting device to splint the whole body rather than splinting each extremity individually patients with a simple mechanism of injury may be further assessed and their condition stabilized on scene prior to transport if there's no other problems that exist okay now we're going to talk about the history taking you're going to obtain a medical history and be alert for injury-specific signs and symptoms and any pertinent negatives obtain a sample history for all trauma patients and how much and in what detail you explore the history depends on the seriousness of the patient's condition and how quickly you need to transport him or her to the hospital opqst can be limited use in cases of severe injury and is usually too lengthy when you're talking about matters of the airway breathing or circulation and rapid transport require immediate attention and then there's your secondary assessment so it's basically that physical exam and if significant trauma has likely affected multiple systems start with a secondary assessment of the entire body to be sure you have found all of the problems and injuries begin with that head to toe work systemically towards the feet checking the head chest abdomen extremities and back the goal is to identify hidden and potentially life-threatening injuries use the dcap btls approach to assess the muscular skeletal system when lacerations are present in any extremity an open fracture must be considered bleeding control and dressings must be applied any injury or deformity of a bone may be associated with vessel or nerve injury obtain a baseline neurovascular assessment and always recheck the neurovascular function before you splint and otherwise manipulate the limb examinations of an injured limb should include the six p's of the musculoskeletal assessment pain paralysis paresthesia which is numbness or tingling pulselessness power and pressure and then determine a baseline set of vital signs and then there's the reassessment of course repeat the primary assessment to ensure your interventions are working as they should a reassessment should be performed every five minutes for unstable patients and 15 for stable interventions we're going to assess the patient's overall condition stabilize the xabc's and control any serious bleeding in a critically injured patient you should secure the patient to the long backboard to minimize the spine pelvis and extremities and provide prompt transport to a trauma center in this situation a secondary assessment is a waste of valuable time reassess the patient and route to the emergency department and if the patient has no life-threatening injuries you can take the extra time at scene to stabilize the patient's overall condition after assessing the extremity apply a secure splint commercial or otherwise to stabilize injury prior to transport and then there's the communication and documentation so you need to document complete descriptions of the injuries and the mois associated with them document the presence of absence or of circulation motor function or sensation distal to the extremity in that is injured after manipulation or splinting the injury and on arrival at the hospital all right so let's talk about the emergency care for these patients perform a primary assessment and stabilize the patient's ex abcs if needed perform a secondary assessment of either the entire body or the specific area of injury be alert for signs and symptoms of internal bleeding and follow the steps in skill drill 31 or 32-1 when caring for patients with musculoskeletal injuries splinting a splint is a flexible or rigid device that is used to protect and maintain the position of an injured extremity unless the patient's life is in immediate danger you should split off fractures dislocations and sprains before you should move the patient it reduces pain and makes it a lot easier to transport and transfer the patient so when you splint it will help prevent the following further damage to the muscles spinal cord peripheral nerves and blood vessels if um um from broken ends bone ends in a laceration of the skin by broken bones it could restrict restriction of blood vessel flow resulting from pressure of bone ends on blood vessels or excessive bleeding of tissues at the injury site caused by broken bones increased pain from movement of the bone ins and paralysis of the extremities general principles of splinting you want to remove the clothing from that area of any suspected fracture or dislocation so that you can inspect the extremity for that d-cap btls note and record the patient's neurovascular status distal to the site of the injury including pulse sensation and movement cover open wounds with dry stale or sterile dressings before splinting do not move the patient before splinting an extremity unless there is an immediate danger to the patient or unless there are threats defined in the primary assessment of the ex-abcs that are unable to be corrected if a suspected fracture of the shaft of the bone be sure to stabilize the joints above and below the fracture and with injuries in and around the joint be sure to stabilize the bones above and below the injured point pad all rigid splints to prevent local pressure and discomfort to the patient when applying the splint maintain manual stabilization to minimize movement of the limb and support the injury site if the fracture of the long bone shaft has resulted in severe deformity use constant gentle manual traction to line the limbs so that it can be splinted if you encounter resistance to the limb alignment splint the limb in its deformed position mobilize at all suspected spinal injuries in a neutral inline position on the backboard and if the patient has signs and symptoms of shock align the limb in the normal at atomic position and provide transport when in doubt splint so let's talk about rigid splints rigid are non-formable splints and are made from firm material and are applied to the sides front and back of an injured extremity to prevent motion at the injury site follow the steps in skill drill 32-2 there are two situations in which you must split the limb in the position of deformity and that's when the deformity is severe and when you encounter resistance or pain when applying gentle traction to the fracture of a shaft of the bone after rigid splints we're going to talk about formible splits and these are sam splints and it stands for suction or splints and vacuum splints okay and you are most likely to use a our structural aluminum manual that's a sam splint and vacuum splints other examples include air splints pillow splints and sling and swath splints a vacuum splint can be easily shaped to fit around a deformed limb instead of pumping air in however you can use a hand pump to pull the air out through the valve follow the steps in skill drill 32-3 to apply a vacuum splint next we're going to talk about pelvic binders those are used to splint the bony pelvis to reduce hemorrhage from bone ends venous disruption and pain all right so hazards of imp improper splinting compressions can result of nerves tissues and blood vessels also there's a dislay and transport of the patient with a life-threatening injury you could reduce the distal circulation or aggravate the injury or also injure to tissues nerves blood vessels or muscles as a result of excessive movement of the bone or joint so transportation very few if any muscular skeletal injuries justify the use of excessive speed during transport if a patient has a pulseless limb it must be given a high priority so if the treatment facility is an hour or more away a patient with a pulseless limb should be transported by a helicopter or immediate ground transportation so let's talk about specific muscular skeletal injuries okay and um so the clavicle or collar bone is one of the most commonly fractured bones in the body it occurs commonly in children when they fall with an outstretched hand and a patient with a fracture to the clavicle will report in the pain in the shoulder and will usually hold the arm across the front of his or her body generally swelling and point tenderness occur over the clavicle the clavicle lies directly under or over major arteries veins and nerves therefore fracture of the clavicle may lead to neurovascular compromise fractures of the scapula or shoulder blade occur much less frequently because the bone is well protected by many large muscles always almost always result in of a forceful direct blow to the back directly over the scapula it is associated with chest injuries not the fractured scapula itself that pose the greatest threat of long-term disabilities so abrasions contusions and significant pain will occur and the patient will often limit the use of the arm because of the pain at that fractured site okay so the joint below the outer end of the clavicle and the acronym process of the scapula is called the acro clavicle joint or the ac joint this joint is frequently separated during sports such as football or hockey when a player falls and lands on the point of the shoulder driving the scapula away from the outer end of the clavicle these fractures can all be splinted efficiently efficiently with a sling and swath then there's the dislocations of the shoulder so basically the humeral head most commonly dislocates anteriorly coming to lie in front of the scapula as a result of forceful adduction and external rotation of the arm shoulder dislocations are extremely painful some patients may report numbness in the hand because of the either the nervous or circulatory compromise stabilizing an interior shoulder dislocation is difficult because any attempt to bring the arm in towards the chest wall will produce pain you must splint the joint in whatever position is most comfortably comfortable for the patient i slinged the forearm and wrist to support the weight of the arm wouldn't secure the arm in a sling to a pillow and chest with a slo swath transport the patient in a seated or semi-seated position all right so now let's talk about fractures to the humerus and they occur either approximately in the mid shaft or distally at which at the elbow and with any severe angulated fracture you should consider applying traction to realign the fractured fragments before splinting them port the site of the fracture with one hand and with the other hand grasp the two humeral condyles just above the elbow pull gently in line with the normal axis of the limb splint the arm with a sling and swath supplemented by a padded board splint on the lateral aspect of the arm then there's elbow injuries so fractures and dislocations often occur around the elbow and the different types of injuries are difficult to distinguish without a radiographic examination they all produce similar limb deformities and require the same emergency care fracture of the distal humerus this type of fracture is known as a supracondylar or intracondylar fracture and it's common in children frequently the fractured fragments rotate significantly producing deformity and causing injuries to nearby vessels and nerves swelling occurs rapidly and is often severe and then there's dislocation of the elbow so this type of injury occurs in athletes and rarely in young children the ulna and radius are most often displaced posteriorly relative to the humerus type of injury there is swelling and significant potential for that vessel and nerve injuries all right so then a fracture of that process of the ulna so it can result in direct or indirect forces and is often associated with lacerations and abrasions and patients will be unable to actively extend the elbow with this type of fracture and then there's fractures of the radial head and it's often missed during diagnosis it generally occurs as a result of a fall on an outstretched arm or a direct blow to the lateral aspect of the elbow attempts to rotate the elbow or wrist can cause discomfort so let's talk about care of all of these elbow injuries all elbow injuries are potentially serious and require careful management always assess diesel distal neurovascular functions periodically with patients with elbow injuries if you find strong pulses and good cap refill splint the elbow injury in the position in which you found it adding a wristling if it seems helpful if you find a cold pale hand or weak absent pulse or poor capillary refill it indicates that the blood vessels have likely been injured if the limb is pulseless and significantly deformed at the elbow apply gentle manual traction in line with the long axis of the limb to decrease the deformity and provide prompt transports for all patients with impaired distal circulation then we're going to now we're going to talk about fractures to the forearm so seen most often in children and older people usually bros both bones break at the same time when the injury is a result of a fall of an outstretched hand in isolated fractures of the shaft of the ulna it may occur as a result of a direct bloat to it such as a nice stick fracture fractures of the radius distal radius which are especially common in elderly patients with osteoporosis are known as a cole's fracture to stabilize fractures of the forearm and wrist you can use padded board air vacuum or pillow splits and then there's injuries to the wrist and hand so dislocations are usually associated with a fracture resulting in a fracture dislocation another common wrist injury is an isolated non-displaced fracture of the carpal bone especially at the scapuloid so because of the fingers and hands are required to function in such intricate ways any injury that is not treated properly may result in permanent disability as well as deformity so you want to follow the steps and skill drill 32-4 to splint the hand and wrist next we're going to talk about fractures of the pelvis so it often results from a direct compression in the form of a heavy blow that laterally crushes the pelvis it may be accompanied by life-threatening blood loss from a laceration of blood vessels effects affixed to the pelvis at certain key points up to several liters of blood may drain into that pelvic space and in the retroperitoneal space which lies between the abdominal cavity and the posterior abdominal wall and it can result in significant hypotension shock and death pelvis fractures can lacerate the rectum vagina and bladder suspect a fracture of the pelvis in any patient with this who sustained a high velocity injury and complains of discomfort in the lower back or abdomen deformity or swelling may be very difficult to see the most reliable signs of a fracture of the pelvis is simple tenderness or instability on a firm compression and palpation assess for tenderness patients in stable condition can be secured to a long backboard or scoop stretcher to stabilize isolated fractures to the pelvis the figures on this slide show how to assess a pelvic region for tender or instability and then you have dislocations of the hip so the hip is a very stable ball and socket joint it dislocates only after significant injury most dislocations of the hip are posterior most commonly occurring as a result of a motor vehicle crash in which the knee meets with the direct force and the entire femur is driven posteriorly dislocation of the hip is associated with very distinctive signs severe pain resistance of movement tenderness on palpation and the ability to palpate the femoral head deep within the muscles of the buttocks as with any injury do not attempt to reduce the dislocated hip in the field unless medical control directs you to do so splint the dislocation in the position of deformity and place the patient supine on a long backboard support the affected limb with pillows and rolled blankets to secure the limb to that backboard all right next we're going to talk about fractures of the proximal femur so fractures of the proximal end of the femur are common fractures especially in older people and people with osteoporosis the break goes through the neck of the femur all right and across the proximal shaft of the femur patients display very characteristics deformity they lie with one leg externally rotated and the injured limb is usually shorter than the opposite uninjured limb patients typically are unable to walk or move that leg and the hip region is usually tender on palpation and gent gentle rolling of the leg will cause pain but will not do further damage you want to assess the pelvis for any soft tissue injury and bandage splint the lower extremity and transport to the emergency department patients with patients may have significant blood loss so you treat with high flow oxygen my monitor vital signs and be alert for signs of shock okay now let's talk about femoral shaft fractures so it can occur in any part of the shaft from the hip region to all the way down to the knee joint what happens following the fracture is the large muscles of the thigh spasm in any attempt to splint that unstable limb the muscle spasm often produces significant deformity of that limb so fractures may be open and there is often a significant amount of blood loss and it is not unusual for hypovolemic shock to develop because of the severe deformity that occurs with these fractures bone fragments may penetrate or press on important nerves and vessels and produce significant damage so carefully and periodically assess the distal neurovascular function in these patients cover any wound with a dry steroid dressing and a fracture of the femoral shaft is best stabilized with a traction splint such as a sagger splint let's talk about traction splints neck so these are used to secure fractures of the shaft of the femur which are characterized by pain swelling and deformity of the mid thigh excessive traction can be harmful to an uninjured limb so goals of inline traction include we want to stabilize fractured fragments to prevent excessive movement and align the limbs significantly to allow it to be placed on the splint um avoid potential neurovascular compromising do not use attraction splint for any of the following conditions so we're not going to use them in an upper extremity or injuries close or at evolving the knee or injuries of the pelvis then we're not using it for partial amputations or avulsions with bone separation or lower leg foot or any ankle injury to apply a hair traction splint we're going to follow the step steps and skill drill 32-5 and the following steps in skill drill 32-6 to apply the sagger traction splint now we're going to talk about injuries to knee ligaments the knee is very vulnerable to injury ligament injuries range from mild sprains to complete dislocations of the joint the patella can also dislocate any bone elements of the knee can fracture okay so the knee is especially vulnerable to ligament injuries which occur when abnormal bending and twisting forces are applied to the joint the patient will report pain in the joint and be unable to use the extremity normally so swelling bruising tenderness and fluid in the joints are generally present you should splint all success suspected knee ligament injuries the splint should extend from the hip joint to the foot stabilize the bone with the injured um injured joint and bone below it a variety of splints can be used included a padded rigid long leg splint or two padded board splints when it comes to dislocations of the knee these are true emergencies that may threaten the limb when the knee is dislocated the ligaments that provide support to it may be damaged or torn always check the distal circulation carefully before taking any other step the direction of the dislocation refers to the position of the tibia with respect to the femur so posterior knee dislocation are the most common they occur in most in almost half of the cases the medial dislocations result from a direct blow to the lateral part of the leg patients will typically complain of pain in the knee and report that the knee gave out complications include limb threatening patello artery disruption injuries to the nerves and joint instability if adequate distal pulses are present splint the knee in the position in which you find it and transport promptly medical control may instruct you to attempt to realign a deformed pulseless limb to reduce compression of that popliteal artery and restore that distal circulation all right so fractures about the knee so they may occur at the distal end of the femur or at the proximal end of the tibia or in the patella management of two types of injuries are as follows so if there is adequate distal pulses and no significant deformity splint the limb with the knee straight if there is an adequate pulse and significant deformity splint the knee and the position of the deformity if the pulse is absent below the level of the injury suspect possible vascular and nerve damage and contact medical control never use attraction splint if you suspect a fractured knee all right now let's talk about dislocations of the patella so usually the dislocated patella displaces to the lateral side the displacement produces a significant deformity in which the knee is held in a moderately flexed position and the patella is displaced to the lateral side of the knee splint the knee in the position in which you find it most often this is with the knee flexed to a moderate degree apply a padded board splint to the medial and lateral aspects of the joint extend from the hip to the ankle injuries to the tibia and phibia so fracture of the shaft of the tibia amphibia occur at any place between the knee joint and the ankle joint often both bones are fractured at the same time even a single fracture may result in severe deformity with significant angulation or rotation often fractures of the tibia are relatively common these fractures should be stabilized with padded rigid long leg splints or an air splint that extends from the foot to the upper thigh correct severe deformity before splinting by applying gentle longitudinal traction and then there's ankle injuries so the ankle is commonly in injured joint and ankle injuries occur in people of all ages and range in severity from a simple sprain to a severe fracture dislocation in ankle injuries that produce pain swelling localized tenderness or the inability to to bear weight it must be evaluated by a physician the most frequent mechanism of an ankle injury is twisting which stretches or tears the supporting ligaments you want to manage injuries to the ankle as the following so dress all open wounds assess distal neurovascular function correct any gross deformity by applying gentle longitudinal traction to the heel before reassessing traction apply the splint and then there's foot injuries so they can result in the dislocation or fracture of one or more of the tarsals metatarsals or phalanges of the toes frequently the force of the injury is transmitted up the legs to the spine producing a fracture of the lumbar spine if you suspect the foot is dislocated immediately assess for pulses and motor and sensory functions if pulse is present immobilize the extremities using a splint leaving the toes exposed to assess neurovascular function if the pulses are absent contact medical control injuries to the foot are associated with significant swelling but rarely with gross deformity to splint the foot apply a rigid padded board splint or air splint or a pillow splint stabilizing the ankle joint and the foot leave the toes exposed when the patient is laying on the stretcher elevate the foot approximately six inches to minimize swelling okay sprains and strains treat every severe sprain as if it's a fracture general treatment is to that of the fracture and includes rice's okay so rest ice compression elevation and splinting then there's amputations so you want to control bleeding and treat for shock surgeons today can occasionally reattach amputated parts with partial amputations make sure to immobilize the part with bulky dressing and splint to prevent further injury do not sever any partial amputations control any bleeding from the stump and if bleeding severe quickly apply a tourniquet with a complete amputation make sure to wrap the clean part in a sterile dressing and place it in a plastic bag follow local protocols regarding how to preserve amputated parts the goal is to keep the part cool without allowing the part to freeze or develop frostbite the amputated part should be transported with the patient to the appropriate resource hospital next let's talk about a condition called compartment syndrome compartment syndrome is a limb threatening condition characterized by local tissue swelling within the compartment blood flow decreases inside the muscle compartment ischemia results in anaerobic metabolism results tissues become damaged and can die definitive treatment is a surgical procedure called aphasiotomy an incision through the skin and fascia allows the swollen muscle to expand reducing pressure inside the compartment compartment syndrome typically develops within six to 12 hours after the injury usually as a result of excessive bleeding a severely crushed extremity and the rapid return of pulse to that ischemic limb signs and symptoms include pain that is out of proportion to the injured extremity pain on a passive stretch of the muscles within the compartment and altered sensation additional signs may occur pallor and decrease power okay if you suspect that a patient has compartment syndrome splint the affected limb keeping it level of the heart and provide immediate transport reassess neurovascular status frequently during transport okay so that concludes chapter 32 and we're going to go ahead and go through the review questions to see what we've learned okay skeletal muscle is also referred to and if you remember us talking about it it is striated muscle and that is because of those lines in the muscle so striated muscle you respond to a soccer game for a 16 year old male with severe ankle pain when you deliver him to the hospital a physician tells you that he suspects a strain that means what does that mean that means c so stretching or tearing of those ligaments with partial or temporary dislocation of the bone ends a young male with a musculoskeletal injury is unresponsive you will not be able to assess what will we be able to assess and we know that that's probably the sensory sensory right can you feel this or can you move this because he's unconscious the purpose of splitting a fracture is to well we want to prevent those motions of the bony fractures and making uh reducing any further injuries right a motorcycle has crashed his bike and has a closed deformities to both of his mid shaft femurs he's conscious but restless has skin is cool and clammy and his radial pulses are weak and rapid the most appropriate splinting techniques would be i think we should probably put him on a long backboard yep um along securing him to the long backboard allowing the long backboard to act as the splint to effectively mobilize a fractured clavicle you should what should we do and we are just going to do that sling and swath and that's going to help minimize the movement of that the clavicle a patient tripped fell and landed on their elbow she's in severe pain and has obvious deformity to her elbow what do we want to do we know that the very first thing we do is we manually stabilize the injury and then we assess for that pms so manually stabilize as always first when treating an open fracture you should and we know that we want to prevent more infection so they want us to cover that wound to prevent that more infection which of the following musculoskeletal injuries is the greatest risk for shock due to blood loss let's see femurs are pretty bad but also pelvic fractures pelvic fractures have those large vessels inside and so it would be as a result of slicing with those large vessels so it's pelvic fracture a injured patient has an injured knee riding a bicycle she's laying on the ground and her leg is flexed with severe pain she can't move it you reassess obvious deformity to her left knee distal pulses are present and strong the most appropriate treatment is what is the most appropriate treatment and that's going to be a dislocation so we want to make sure that we splint the leg in the position that it's found okay so that concludes uh chapter 32 lecture and review questions if you like this lecture go ahead and subscribe to the channel because we're going to complete the book