1.
INSTITUTE OF HEALTH SCIENCES
SCHOOL OF MIDWIFERY AND NURSING
DEPARTMENT OF ADULT HEALTH NURSING
AND MIDWIFERY
PREPARED BY:- KIDANE DINKU.
INITIAL EVALUATION AND MANAGEMENT
OF ORTHOPEDIC INJURIES
Presentation
2/7/2023
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Outline presentation
2/7/2023
 Objective
 Introduction
 Fracture, Flail Chest
 Dislocation, Sprain And Strain.
 Principles for bone and joint injuries.
 Splint specific fractures.
 Management for dislocation.
 Management for sprain and strains
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Objectives
2/7/2023
After studying this chapter, the student will be able to:
 Define fracture, dislocation, sprain and strain.
 Recognize f/a principles for bone and joint injuries.
 Demonstrate how to splint specific fractures.
 Demonstrate first aid management for dislocation.
 Apply first aid management for sprain and strain.
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Introduction
 Musculoskeletal trauma involves injury to one or more of the
following structures:
Bone: A unit of the skeleton composed of the hardest variety of
connective tissue.
 Bones give shape and support to the body.
 In addition to surrounding and protecting vital organs, they serve as
points of attachment for the muscles of the limbs, making movement
possible.
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Cont…
Joint: The area where two or more bones articulate with one
another.
 Joints are usually classified in terms of the amount of motion
permitted at the articulation.
 Most joints of the extremities are synovial joints, which allow
the greatest amount of motion.
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Cont…
Ligament: A bundle of connective tissue forming part of the
fibrous capsule surrounding a joint and attached to it.
 Every joint of the extremities is reinforced by two or more
ligaments
Tendon: The fibrous structure connecting a voluntary muscle to
bone, cartilage, or ligaments.
 Tendons enable muscles to effect motion in the joint or body
area to which they are attached
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Orthopedic injuries to these structures include the
following:
 Fracture -is a complete or incomplete break in the continuity of bones.
 Fracture -is a complete or incomplete break in the continuity of
bones.
 Dislocation -is complete or Partial separation of the joint
 Sprain- is a joint injury caused by excessive stretching of the
supporting ligaments.
 Strains- are caused by stretching or tearing of a muscle.
 Subluxation -Partial disruption of a joint, in which some degree of
contact between the articular surfaces remains
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Cont…
2/7/2023
Fracture-dislocation or fracture-subluxation
 Disruption of a joint combined with fracture of at least one of
the bones involved in the articulation.
Diastasis:
 A separation of the interosseous membrane connecting two
syndesmotic joints as seen between the radius and ulna and
tibia and fibula.
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Mechanism of injury
2/7/2023
By. Kidane D ( Bsc in Emergency and Critical Care Nurse )
 Motor vehicle accident
 Industrial accident (machine)
 Gunshot injury
 Fall from a height, trivial
 Fighting injury
 Pathologic fractures
 Stress fractures
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Patient’s History
2/7/2023
 The value of the history in cases of orthopedic trauma is often
underestimated.
 Knowing the precise mechanism of injury may be the key to
diagnosing some fractures or dislocations.
 For example, a history of shoulder injury combined with the
complaint of dysphagia may be the only clue to the existence
of posterior sternoclavicular dislocation.
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Cont..
2/7/2023
 History taking should not necessarily be limited to orthopedic
issues.
 Depending on the situation, a general medical history should be
obtained because it may have implications for further workup.
 Relevant issues may include a history of cancer, heart disease or
neurologic disease, taking anticoagulant medication.
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Initial evaluation of orthopedic injuries
2/7/2023
 Essential components of Initial evaluation of orthopedic injuries
 General patient assessment
 Examination of the injured limb
 Evaluation of circulation, sensation, and movement
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2/7/2023
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I. General patient assessment
2/7/2023
 Associated life threatening injuries may be missed if evaluation
of the patient is not systematic.
 Limb injuries are not life threatening unless there is excessive
bleeding from an open wound
Note: Fx to pelvic = 3L bleeds ,
Fx to femoral =1-1.5 bleeds,
Fx to tibia = 0.5-1 L bleeds.
 Fx to each ribs bleeds 150ml,
Fx to humerus =0.5-1L bleeds,
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ll. Examination of the injured limb
2/7/2023
1. Inspect the injured limb and compare it with the opposite, uninjured
limb.
2. Gently and carefully cut away any clothing covering the wound, if
necessary.
3. When you examine the limb, you may find any one of the following:
a. Open wound
b. Deformity
c. Swelling
d. Bruising
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Cont …
2/7/2023
4. Gently feel the injured limb for points of tenderness- is the
best indicator of an underlying fracture, dislocation, or sprain.
5. To detect limb injury, start at the top of each limb and using
both hands, squeeze the entire limb in a systematic, firm
manner, moving down the limb and away from the body.
6. As you conduct the hands-on examination, ask the patient
where it hurts most.
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III. Evaluation of circulation, sensation, and movement.
2/7/2023
1. Once you suspect limb injury, you must evaluate the circulation and
sensation in that limb.
2. Any injury may have associated blood vessel or nerve damage.
3. It is essential to check circulation and sensation after any movement
of the limb.
S/S
 tingling or numbness in the extremity;
 nerve damage or lack of circulation.
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Cont …
 After you have made a careful visual and hands-on
examination, and if the patient shows no sign of injury, ask the
patient to move the limb carefully.
 If there is an injury, the patient will report pain and refuse to
move the limb.
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Imaging
2/7/2023
 The joints above and below a fracture should generally be imaged
because injury at the proximal or distal joint may coexist with long
bone fractures.
 Injuries that may require special views or advanced
imaging modalities in order to be visualized include
acromioclavicular separation, fracture of the scaphoid, posterior
shoulder dislocation, and sternoclavicular dislocation.
 Plain radiographs are still the mainstay for fracture diagnosis
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Fracture
2/7/2023
Types of Fracture
1. Closed fractures- closed (simple)
fractures are those not associated with
open wounds on the surface of the
body.
2. Open fractures – open (compound)
fractures are those associated directly
with open wounds.
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Signs and symptoms of fracture
2/7/2023
 History of trauma
 Pain, Swelling,
 Inability to use the injured body part
 Tenderness and bruising
 Deformity, abnormal movement (sure signs of fracture).
 Altered neurovascular status
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Initial management /First aid measures
2/7/2023
Objectives of first aid
 To prevent blood lose
 To keep the broken bone joints from moving.
 To give care for shock.
 To relief pain
 To transport the victim to hospital
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Fracture of the scapula
2/7/2023
 Fracture of the scapula (shoulder blade) is
generally the direct result of the impact of
a fall or an automobile collision.
 Dislocations of the shoulder joint, sprains
and contusions are common in this area.
 First aid consists of applying a sling and
bandaging the victim’s upper arm to his
chest wall
Consists of applying a sling to
elevate and immobilize the arm
and shoulder blade.
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Fracture of the humerus (The bone of the upper
arm)
2/7/2023
First aid for a closed humerus fracture
Place a pad in the victim’s arm pit, apply a splint or improvised
splint tied in place above and below the break area .
Support the forearm with a sling that doesn’t produce upward
pressure at the fracture site.
Bind the victim’s upper arm to his chest wall
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Cont…
2/7/2023
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Fracture of fore arm and wrist
2/7/2023
 The two bones of the fore arm (ulna and radius) may be
fractured individually or together.

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First aid measures
2/7/2023
 Fractures in the mid portion of the fore arm and wrist are
treated in the same way as fractures of the shaft of the
humerus.
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Flail Chest
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 Flail Chest
 Direct injury to the chest resulting in an
unstable segment of the chest wall that
moves separately from remainder of
thoracic cage
 Typically results from two or more
fractures on 2 or more ribs
 Typically accompanied by a pulmonary
contusion
 Physical exam = paradoxical movement of
chest segment
 Treatment = improve abnormalities in gas
exchange
 Early intubation for patients with
respiratory distress
 Avoidance of overaggressive fluid
resuscitation

29.
CONT…
 Segment of chest wall that don’t have bony continuity with
the rest of thoracic cage .
 Associated multiple rib fracture
Clinical manifestation
 Disrupts normal chest movement .
 Paradoxical chest movement during breathing and pulmonary
contusion are common.

30.
CONT.
 Palpation- creptus (rib/cartilage fracture) , uncoordinated
respiratory motion
 Diagnosis :- CXR- multiple rib fracture
- ABG- respiratory failure with hypoxia
 Management – Initial – adequate ventilation
-administration of humidified air
 -fluid resuscitation for
hypotension(careful monitoring of fluid is mandatory-CVP)

31.
Bulky Dressing for splint of Flail Chest
 Use Trauma bandage and Triangular
Bandages to splint ribs.
 Can also place a bag of D5W on area
and tape down

32.
Fracture of the upper leg
2/7/2023
 Fractures of the shaft of the femur usually result from falls or
traffic injuries.
 The victim is in severe pain and shock and markedly disabled.
 The foot is characteristically turned outward and the limb
shortened owing to overlapping of the bone ends due to muscular
spasm.
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First aid measures
2/7/2023
 If the victim is to be transported only for short distance on a
stretcher, place a blanket between the legs and bind them together.
 To apply the board splint, assemble needed supplies.
 If you use improvised board splints, they should be well padded
and should reach from the victim’s armpit on the outer side and
groin or the inner side to below his heel
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Cont…
2/7/2023
 The bandages will be tied on the following areas: just below the arm
pit, at the abdomen, at the hip, above and below the fracture site, at
the lower leg and ankle and foot with figure of eight bandage
 Don’t try to cleanse open wound (if present).
 If possible apply a traction splint for the fracture of the shaft of the
femur.
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Fracture of the kneecap (Patella
2/7/2023
 The patella is in front of the knee Joint.
 It is fractured usually by direct injuries sustained when control of
the knee is lost, with the front thigh muscles pulling violently on
the kneecap.
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First aid measures
2/7/2023
Apply a pillow splint about the knee or padded splints from
below the victim’s heel to his buttocks along the back of the leg,
with the leg extended.
Raise the leg slightly to prevent swelling.
Send to hospital or a health center.
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Fracture of the lower leg
2/7/2023
 The bones of the lower leg are the tibia (shinbone), which
supports the weight of the body and the fibula, which forms the
outside wall of the ankle and is on the outer side of the leg.
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Fracture of ankle and foot
2/7/2023
 The ankle is made up of the lower ends of the tibia and fibula
and the first bone of the foot (the talus). Fractures in this area
occur most commonly in active sports, in falls, and in motor
vehicle accident.
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First aid measures
2/7/2023
Loosen or remove the victim’s shoes, and hose (socks) and
keep him lying down with his leg elevated.
 For an open wound apply large bulky dressings.
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General Rx cont’d…
2/7/2023
All limb injuries are treated in the same way in the field.
A..Fix ABC problems first; Administer anti pain
B. Cover open wounds with dry, sterile dressings.
C. Apply firm but gentle pressure to control bleeding, if
necessary.
D. Apply a cold pack to painful, swollen, or deformed
extremities.
E. Splint the injured limb and immobilize it.
F. Immoblization prevents displacement of reduced Fx, reduce
pain.
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Splinting
2/7/2023
 All limb injuries should be splinted before the
patient is moved, unless the environment prevents
effective splinting or threatens the pt’s life.
Purpose:
 prevents the movement of broken bone ends, a
dislocated joint, or damaged soft tissues, thereby
reducing pain.
 Controls bleeding and decreases the risk of
additional damage.
 Prevents closed fractures from becoming open
fractures during movement or transport.
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General principles of splinting
2/7/2023
1. Note and record PMS distal to the point of injury, both before and after
splinting.
2. Cover all open wounds with a dry, sterile dressing before applying the
splint.
3. Do not move the patient before splinting, unless there is an immediate
danger to the patient or the EMR.
4. Immobilize the joint above and the joint below the injury site
5. Splint the limb without moving it unnecessarily.
6. When in doubt, splint.
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Materials used for splinting
1. Rigid splints
 Are made from firm material ; are applied to the sides, front, or
back of an injured extremity.
 Common types of rigid splints include:
Padded board splints, Molded plastic or aluminum splints
.Padded wire ladder splints, Folded cardboard splints
2. Air splint
 After it is applied, the splint is inflated.
 comfortable for the patient and provides uniform pressure to a
bleeding wound.
3. Iprovised
2/7/2023
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Open or compound fracture
2/7/2023
- This is a fracture in which the fracture hematoma
communicates with skin or mucous membrane.
- Infection is the most feared complication.
- may cause delayed healing, non union, sepsis or even death.
- It is a surgical emergency.
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Open or compound fracture…..
2/7/2023
Principles of management:
1. Early wound debridement & thorough irrigation with saline.
2. Broad Antibiotics & Tetanus prophylaxis
3. Rigid immobilization with access to the wound
4. Delayed wound closure! Never close a compound fracture
immediately in an attempt to convert it to a closed one.
You’ll cause a severe anaerobic infection!
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Orthopedic consultation in the ED
2/7/2023
 In many cases, such as fracture of the hip, the need for
hospital admission and/or orthopedic consultation in the ED.
 In some situations, however, differences of opinion may exist
regarding whether the patient needs to be seen by an
orthopedist in the ED.
 Even patients with injuries that ultimately may require
surgical repair, such as an unstable ankle fracture, sometimes
may be immobilized and discharged with a referral for prompt
orthopedic follow-up.
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Complications of Fractures
2/7/2023
I- Soft tissue Injuries
 Arteries, Nerves and Viscera may be injured
II- Compartment syndrome
 Is a dangerously increased pressure within the enclosed fascial
compartments of extremities.
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Complications of Fractures…
2/7/2023
III- Infection
- Usually complicates open fractures
- Chronic osteomyelitis may be resulted.
- Cleaning and adequate debridement is the most critical
factor in preventing infection.
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Cont…
2/7/2023
 The high compartmental pressure causes Ischemia and
necrosis of soft tissues in the compartment.
 Common to especially fore arm and leg.
 Severe pain, especially with passive flexion of fingers is the
earliest indicator.
 4Ps - Paresthesia, Paralysis, Pallor or Pulselessness may
develop later.
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Dislocation
2/7/2023
 A dislocation is a displacement of a bone end
from the joint particularly at the shoulder, elbow,
fingers or thumb usually as a result of a fall or a
direct blow.
 Unless proper care is given, a
dislocation may occur repeatedly.
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Signs and symptoms of dislocation
2/7/2023
 Swelling.
 Obvious deformity.
 Pain upon movement.
 Tenderness to touch.
 Discoloration.
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First aid measures
2/7/2023
 First aid should be essentially the same as for closed fractures.
 Splint and immobilize the affected joint in the position in which it
was found.
 Apply a sling if appropriate.
 Elevate the affected part if a limb is involved.
 Seek medical attention promptly.
 Never attempt to reduce a dislocation.
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Sprain
2/7/2023
 A sprain is an injury to a joint, ligament or muscle and tendon in
the region of a joint.
 It occurs usually as result of forcing a limb beyond
the normal range of movement.
The ankles, fingers, wrists and knees are most often sprained.
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Signs and symptoms of sprain
2/7/2023
 Swelling
 Tenderness
 Pain upon motion
 Discoloration
 It might be difficult to differentiate a sprain from a closed
fracture
with out an X-ray.
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First aid measures
2/7/2023
 If the victim’s ankle or knee is affected, do not allow him to walk.
 Loosen or remove the victim’s shoes, apply a pillow or blanket, splint
and elevate the victim’s leg to prevent swelling .
 Keep the injured part raised for at least 24 hours.
 Apply cold wet pad or place a small bag of crushed ice on the
affected area over a towel intermittently, to protect the victim’s skin.
 If swelling and pain persist, seek medical attention.
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Strain
2/7/2023
 Strains are injuries to muscle resulting from over stretching.
 Commonly strains occur on the back muscles, due to improper lifting
technique.
 To avoid back strain when a heavy object must be lifted, observe the
following precaution.
 Place the feet close to the object firmly and apart.
 Lift slowly, pushing up with the strong thigh and leg muscles are bearing
the weight.

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First aid measures
2/7/2023
 Bed rest, heat and use of a board under the mattress for firm
support are recommended for person with a strained back
 Cool the area by applying an ice pack or cold compress for the
first 24 hours.
 After 24 hours, apply heat, warm, wet and rest care.
 Seek medical care; (severe back strains should be seen by a
physician).
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Prevention of accidents resulting in skeletal and muscular
injuries
2/7/2023
The following discussion on prevention will limit it self to additional
consideration regarding motor vehicle accidents:
 Motor vehicle accident prevention
 What follows is intended to provide a basis for discussion of the
over all high way accident.
 Driving skill, judgment and condition of driver
 Vehicle condition
 Environmental conditions and Pedestrian safety
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Falling accidents
2/7/2023
Falls are the second leading cause of accidental death.
 Ranking behind motor vehicle fatalities and a head of fire and burn
fatalities.
 The reader should further develop his/ her understanding regarding
the following types of accidents by referring standard references.
 Slipping and Tripping (Slight Walking) Hazards
 Climbing and Reaching
 Special Precautions
 Joint and Muscle Tissue Injury Prevention
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Summary
2/7/2023
 Evaluation of orthopedic injuries is the cornerstone of the patients
that used to identifying and treating orthopedic urgencies and
emergencies.
 Initial evaluation is crucial and critical to minimizing morbidity
and mortality.
 Immobilization is necessary for an orthopedic injury to heal
properly. Injured bones, ligaments, tendons, and more will incur
further damage if the affected areas aren't immobilized.
 Keeping the area from moving also helps reduce pain.
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References
2/7/2023
1.Tintinalli’s Emergency Medicine, A Comprehensive Study
Guide Ninth Edition page number 1767.
2.Annual Update in Intensive Care and Emergency Medicine
ISBN 9783030060664 ISBN 9783030060671 (eBook)
https://doi.org/10.1007/9783030060671
3. Advanced Trauma Life Support ATLS Ninth Edition
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