Vol.4-Ch.9 "Orthopedic Trauma" Flashcards
What % of bone tissue is replaced each year?
20%
Haversian Canals Vs Perforating Canals?
Haversian Canals are small tubes in bones that allow for small blood vessels to travel within the bone
Perforating Canals allow for blood vessels to enter and exit the bones, allowing for exchange and flow of blood and tissues
Osteocytes VS Osteoblasts/Osteoclasts
Osteocytes are bone cells trapped in a matrix in the bones and help regulate collagen, calcium, phostphate, carbonate, and other crystals.
Osteoblasts lay down new bones in areas where stress and growth call for more tissues
Osteoclasts break down bone in areas that don’t need as much bone tissue for support and also to break down for release of calcium when the body needs a surplus
Diaphysis VS Epiphysis VS Metaphysis
Diaphysis is the middle, long shaft of the bone and is structurally strong with a very dense layer and a thin layer to make it lighter
Epiphysis is the end of the bones and is wider and spongy b/c it is Cancellous bone (spongy bone)
Metaphysis is in between the other two, a small section just above the epiphysis; It also houses the EPIPHYSEAL PLATE or growth plate where during childhood, cartilage is generated here and the plate widens. (injury to this in childhood will stunt growth)
What causes bone growth in children?
It occurs when the osteoblasts in the diaphysis deposit salts into the forming cartilage’s collagen matrix in the metaphysis’ EPIPHYSEAL PLATE to create new bone
Where are yellow and red bone marrow stored in bones?
YBM: is stored in semiliquid form fat and is in the central medullary canal, which is the hollow portion of the diaphysis and cancellous bone of the epiphysis
RBM: is in the cancellous bone chambers of the larger long bones, pelvis, and sternum. (it is responsible for manufacturing erythrocytes and other blood cells)
What is the periosteum?
It is the tough fibrous membrane on the outer surface of the diaphysis; is is very vascular and has a lot of nerves that send pain signals and initiate the bone repair cycle. It is also what the tendons attach to
What is cartilage made of?
Collagen
How are bones classified?
By their general shape
Long, short, flat, irregular
carpals and tarsals are only short bones; vertebra and face bones are only irregular
What are the 3 general types of joints (based on amount of movement allowed)
1) Synarthroses (no movement; skull sutures, teeth/jaw juncture)
2) Amphiarthroses (limited movement; vertebrae, sacrum/ilium/pelvis)
3) Diarthroses (relatively free movement; typical joints)
What are the 3 categories of Diarthroses joints?
1) Monoaxial Joints (hinge; knee, elbow, finger & Pivot; axis or atlas that have 180 degree rotation)
2) Biaxial Joints (Condyloid or gliding, ellipsoidal, saddle)
3) Triaxial Joints (ball and socket)
What forms a joint capsule?
A joint capsule is formed when Ligaments surround a joint (knee for ex), within the capsule is SYNOVIAL FLUID, which reduces friction and circulates O2, nutrients, and waste. CARTILAGE acts like a sponge that pushes out synovial fluid when compressed and soaks it up when relaxed. There are BURSAE which are sacs filled with synovial fluid the help absorb shock
Tendon VS Ligament?
Tendon = bone to muscle Ligament = bone to bone
7 types of muscle injury:
1) CONTUSION - damages muscle cells and blood vessels, blood leaking into interstitial space and across muscle will cause inflammatory response; swelling of injured limb may be noted. In severe cases on large muscles, a hematoma may be caused big enough to contribute to hypovolemia
2) COMPARTMENT SYNDROME - when muscle injury causes swelling within the inelastic fascial envelopes called compartments this will reduce capillary blood flow which causes a histamine release at location, increasing permeability and worsening swelling. End result is compression of nerves and capillaries at muscle and PAIN DISPROPORTIONATE TO APPEARANCE OF INJURY. Distal pulse and cap refill may be normal b/c it takes much more pressure to shut these flows off, numbness from nerve compression may be present
3) PENETRATING INJURY
4) FATIGUE - occurs when muscles reach their performance limits by using its O2 and energy reserves causing a build up of metabolic biproducts that cause hypoxia, acidic, toxic, and energy deprived state only relieved by oxygen flow restoration
5) CRAMPS - not an injury but a painful muscle spasm or contraction. Can be helped by repositioning or massaging. Can be caused by electrolyte imbalance like hypocalcemia or lactic acid accumulation
6) SPAMS - An intermittent (clonic) or continuous (tonic) contraction of the muscle, usually subsides with rest
7) STRAIN - occurs when the muscle fibers are overstretched and damaged
What are the 3 types of joint injuries?
1) Sprain - tearing of of a joint capsule’s connective tissue (ligament(s)); pain is immediate and swelling follows soon after. Put into 3 grades (on another card)
2) Subluxation - a PARTIAL bone end displacement from its position within a joint capsule, this may tear or just severely stretch ligaments. It reduces joint integrity MORE than a sprain but may present with similar symptoms
3) Dislocation - a COMPLETE bone end displacement, where the joint fixes in an abnormal position with obvious deformity, this carries obvious joint capsule and ligament damage but can also damage nerves and blood vessels
What are the 3 grades of a joint sprain?
Grade I: Minor and incomplete tear; joint stable with minor swelling
Grade II: Significant but incomplete tear; swelling and pain can be severe, joint is intact but unstable
Grade III: Complete ligament tear, may even present as fracture due to severe pain and spasm, joint is unstable
What is parasthesia?
paresis?
anesthesia
paralysis
Pins-and-needles feeling
weakness
loss of sensation
loss of muscle control
What are the 9 types of fractures?
1) hairline - small crack but doesn’t disrupt the total structure
2) Impacted - when bone is compressed on itself, fracture is there but the bone remains in place
3) Transverse - transverse is fractured like impacted where it runs 90 degree but the ends are now displaced
4) Oblique - similar to transverse but the fracture is at a 45 degree angle and displaced
5) Comminuted - fracture that has splintered into several smaller fragments
6) Spiral - occurs when a limb is twisted causing a curved break
7) Fatigued - (stress fracture) occurs due to repeated stress
8) Greenstick - commonly only in kids b/c of their higher percentage of cartilage and bone flexibility. It is when a bone bends and fractures partially on one side; due to the stiffness of the periosteum it won’t want to bend back but will still undergo a healing process which leaves the injured side to be more built up and permanently bowed. Surgeons will often complete the fracture in order to assure equal healing (similar to a buckle or torus fracture)
9) Epiphyseal - fracture in the epiphyseal plate in children, due to the increased size of it during bone growth (most common in the proximal tibia)
What is a rare but serious complication that can occur with a severe bone fracture, usually comminuted frequently caused by crush injuries?
The release of the semiliquid fat (yellow bone marrow) that may find it’s way into a ruptured vein, which would travel through to the lungs and become a pulmonary embolism
According to the Salter-Harris system of classifying growth-plate injuries, what are the 5 types?
Type I: fracture transversing the growth plate, not affecting bone above or below
Type II: fracture involving the growth plate and the bone above (diaphysis)
Type III: fracture involving the growth plate and the bone below (epiphysis)
Type IV: fracture involving the growth plate and the bone above and below
Type V: is a crushing type injury involving the entire distal bone
Describe the bone healing process in 4 steps:
1) Bone injury occurs disrupting the periosteum and local blood vessels/nerves. These vessels bleed into the fracture and the blood clots. The blood clot mixes with collagen to form a fracture hematoma that stops hemorrhaging and weakly immobilizes the fracture
2) Cartilage forming cells migrate into the hematoma from the broken bone ends and begin to repair, forming a more significant mass to stabilize the joint. This mass becomes a Callus
3) Osteoblasts then move into the callus to begin laying down new bone cells to bring the fracture back to bone strength. The callus will eventually be bigger than needed however.
4) Once the callus is done and formed, osteoclasts and osteoblasts will begin laying down or breaking down bone cells in order to “form” the bone back to its needed and possibly original size
What are the 6 Ps in evaluating a Limb Injury?
- pain
- pallor
- paralysis
- paresthesia
- pressure
- pulses
(sometimes poikilothermia or cool to the touch)
What are the 4 categories of musculoskeletal pts?
- Life and limb threatening injury
- life threatening injury , minor musculoskeletal injury
- non life threatening injury, minor musculoskeletal injury
- non life threatening, isolated minor musculoskeletal injury
What are 6 early signs of compartment syndrome?
- feeling of tension in limb
- loss of distal sensation (especially in webs of hands and feet)
- complaints of pain
- condition more severe than mechanism of injury would suggest
- pain on passive extension of extremity
- pulse deficit (late sign)
What are the 4 main basics of musculoskeletal injury care?
- protecting open wounds (put sterile dressing over it)
- proper positioning (attempt to realign or reduce dislocation if no distal pulse is present, splint if there is pulse; splint in the POSITION OF FUNCTION if possible which is half way between flexion and extension; elevate if possible to increase venous drainage and reduce edema)
- immobilize the injury
- monitor neurovascular function
(also local cooling with an ice pack wrapped in a towel to help reduce pain, swelling, and inflammation
When can you try to align a fracture or reduce a dislocation?
How do you do both?
Consider realignment if the limb has no distal pulse, is preventing splinting, or if the bone end is close enough to the skin surface that it runs the risk of becoming an open fracture. Even if limb is not that angulated, if there is no pulse try to move it around lightly until pulse is restored
For fracture, have partner hold proximal portion very tight and still while you place axial traction on distal portion, stop if there is any resistance or great increase of pain
For dislocation apply firm and progressive traction to the limb, pulling the dislocated ends away from each other and try to move them back to a normal positioning. Stop if you get the bone ends to “pop” back into a normal position.
**If you successfully regain a pulse with either then stop the attempt and splint/secure as is, just try to maintain the distal pulse
When should you assess circulatory, motor, and sensory function on splinting an extremity?
Before, during, and after
6 types of splints?
- RIGID (cardboard ones are big, usually need to have padding added for comfort)
- FORMABLE (ladder splint, metal sheet splint, SAM splint, all are malleable and form to limb)
- VACUUME (airtight bag filled with plastic particles, vacuum out air and it forms for limb)
- SOFT (air splints should not be used for long bone injuries above the knee or elbow as they do not prevent joint movement, they also need to be monitored if elevation or temp is a factor as it can change the pressure inside, they can be useful for controlling hemorrhaging though. Pillow splints are good for ankles and feet)
- TRACTION (mostly used for MIDSHAFT femur fractures WITH MUSCLE SPASMS AND NO ADDITIONAL FRACTURES because it helps reduce further injury caused by muscle spasms by pulling the bone ends away from each other so they cant overlap; the BIPOLAR puts traction placed at the foot and pelvis and has the ability to elevate and immobilize it in the air for reduced movement during transport, has a variation called the REEL splint that can bend at the middle and be used for lower and upper limbs; the UNIPOLAR is similar but does not elevate or stabilize.
- OTHER (CRAVATS or VELCRO straps can be used as a sling and swathe)
If a bone fracture is within ____ of a joint, treat it also as a joint injury
3 inches
What two areas make up a pelvic fracture?
which is worse?
They involve either a iliac crest or pelvic ring fracture
A pelvic ring fracture is worse and is considered a critical/high-priority injury (an iliac crest fracture is usually isolated and manageable by just immobilization)
What are the 4 types of pelvic fractures?
Type I: do not involve pelvic ring; involve avulsion fractures and those of the pubis, sacrum, coccyx, ischium, or iliac wing
Type II: involve a single break in the pelvic ring, maintain pelvic stability, and include unilateral ring fractures and symphysis pubis or sacroiliac fractures
Type III: High energy and multiple ring fractures
Type IV: Involve the acetabulum
What specific qualities do the veins in the pelvis have that make them prone to massive hemorrhaging?
They have limited vasculature, no valves, and experience retrograde blood flow when torn
What are the 3 objectives in managing a pelvic fracture?
- stabilize the fracture (pelvic sling or binder)
- support pt hemodynamically
- rapid transport
A traction splint is the best thing for a hemodynamically stable and isolated femur fracture pt but when is it not ideal?
If the pt also has a fracture in the foot, tibia, knee, or pelvis
If you use traction to realign a limb (especially the femur) when should you release the traction?
Hold that traction till the splint is applied
When your pt has a femur fracture, but has other injuries that prevent the time needed to apply a traction splint, what is the next best thing?
Put them on a long spine board with two rigid splint tied to the leg and then tie the injured limb to the uninjured limb
What is special about a tibia/fibula fracture?
Tibia is most common broken leg bone, since it is so close to surface it is usually an open fracture, commonly associated with knee or ankle injuries. Splint FULL LEG and tie injured leg to uninjured leg
What is special about a clavicle fracture?
It is the most commonly fractured bone in the human body, it can be managed by a sling and swathe
What is the best way to handle a humerus fracture?
A “cuff and collar” sling and swathe, this is because typical splinting cannot immobilize the shoulder and cant apply enough pressure without cutting off the axillary artery
What is Colles’ Fracture or “silver fork deformity”
It is referring to a distal radius fracture (most common for radius/ulna fractures) where the bone end moves towards the palm making the wrist resemble the contour of a fork
What changes if a hip dislocation is anterior vs posterior?
Anterior causes a palpable deformity in the inguinal area and the foot turns OUTWARD
Posterior causes the femur head to be buried in the buttocks, possibly infringing the sciatic nerve; foot presents rotating INWARD and knee flexed
How do you care for a dislocated hip?
you can attempt to reduce the posterior dislocation by holding pressure downward on the iliac crest pressing into a spine board, then have the other person flex hip and leg to 90degree and apply firm but gradual pressure to the femur axis, rotating it externally. It may take some time (minutes) for the muscles to relax and allow the femur head to pop back in place. then place pt comfortably on a spine board with rapid transport (if reduction does not occur, place pt back in position found)
What medications are typically used for pain in musckuloskeletal injuries?
diazepam, morphine, and fentanyl (fent can be given intranasal, especially for kids)
What does RICE stand for in strains, sprains, and soft tissue injuries?
- REST
- ICE (for first 48, then heat to increase blood flow circ)
- COMPRESS with elastic bandage
- ELEVATE extremity
