Orthopedic Assessment

Orthopedic assessment is a fundamental EMS skill that requires a working knowledge of not only the anatomy and physiology of the musculoskeletal system, but elements of peripheral vascular and neurological assessment as well. While the focus of EMT training in orthopedic injuries in recent years, particularly at the EMT-B level, can fairly be described as “splint ’em all and let the radiologists sort ’em out,” a thorough and comprehensive orthopedic assessment is within the capabilities of most EMS providers. While the musculoskeletal system includes all 206 bones of the human body and their attached muscles, tendons and ligaments, this article will focus on assessment of extremity trauma only.

A 16-year-old skateboarder injures himself at a local office park. His companions call 9-1-1, and EMTs find the young man sitting on a concrete bench complaining of left ankle pain. He gestures to a flight of steps 20 feet away, and says he was attempting to ride its metal handrail to the next flight and landed awkwardly, twisting his left ankle. He is wearing a helmet and knee and elbow pads, and denies loss of consciousness or any other injuries. He says he was able to walk to the bench, where he is now sitting without assistance, but that the ankle “really tightened up on him,” and he now reports considerable pain.

Vital signs are: heart rate 124 and regular, strong radial pulses; respirations 18 per minute, non-labored; blood pressure 128/76; SpO₂ 98% on room air. Examination of the injured joint reveals mild swelling over the lateral surface of the ankle and intact dorsalis pedis pulses. Palpation of the distal ends of the tibia and fibula, including medial and lateral malleoli, reveal no significant point tenderness, and the patient only complains of “soreness” rated at 5 on a 10-point scale.

Anatomy and Physiology

The division of the musculoskeletal system responsible for locomotion and manipulation of objects is known as the appendicular skeleton and comprises the 126 bones of the arms, legs, and pectoral and pelvic girdles. While the bones of the axial skeleton protect the central nervous system and vital organs and are thus quite robust, the bones of the appendicular skeleton protect less-vital structures and, often being subjected to greater mechanical forces, are more likely to fracture. The clavicle is the single most commonly fractured bone in the human body; as a group, the eight bones of the wrist make up the most commonly fractured area in adults under age 75. In adults 75 and over, hip fractures are most common.

Bones are attached to one another by means of connective tissue known as cartilage. Muscles attach to bones by means of fibrous tendons. Skeletal muscles consist of three basic parts: the fibrous tendon that attaches to the bone to which the muscle is anchored is the origin; the meaty part of the muscle is the belly; and the fibrous tendon that attaches to the bone upon which the muscle acts is the insertion.

In common terminology, injuries to muscles are known as strains, injuries to joints are known as sprains, and injuries to bones are known as fractures. While a thorough assessment may be helpful in differentiating the three, treatment in the field is the same, because proper stabilization of musculosketal injuries is essential to reducing pain and inflammation.

Assessment

Proper assessment of orthopedic injuries focuses on three main findings: pain, swelling and instability. Gently palpate the area in question, feeling for point tenderness, swelling or discernable deformities. It is not necessary to check for instability in the field, but this is often done in the emergency department.

Often the instability will be readily apparent to visual inspection, and manipulation of the limb may yield a finding of crepitus, the characteristic sound or feel of jagged bone ends rubbing together.

In some educational programs, EMTs are taught to test for instability or crepitus by means of a three-point bone check in which the proximal and distal ends of the bone in question are pushed in opposite directions. This is both unnecessary and barbaric; the mere presence of pain and swelling is enough to warrant immobilization and pain relief.

Check and mark the location of pulses distal to the site of injury. With angulated fractures with no distal circulation, it is often permissible to gently straighten the angulation one time in an attempt to restore distal blood flow. If resistance is met, splint in place and rapidly transport to the emergency department.

Check motor and neurological function distal to the extremity site. Often, gross motor function is impaired in long bone fractures, but the patient should be able to wiggle their fingers and toes. It is important to check both motor and neurological function, since motor and sensory nerve pathways are separate.

Auscultatory percussion of long bones has largely been relegated to a parlor trick since the advent of radiography, but it was once a highly useful method for recognizing fractures. Since ambulances do not carry x-ray machines, the technique may still be useful to us, particularly in cases where swelling, crepitus and deformity may not be readily apparent, or when the patient may be so chemically or neurologically impaired as to diminish his sensation of pain. Simply auscultate one end of a long bone and percuss the other; an intact bone will conduct sound in a dull thump, whereas a fractured bone will not, or will be severely diminished in comparison to the uninjured side.

EMTs apply a cold pack to the swollen area and fashion a pillow splint to pad and stabilize the patient’s ankle. Distal sensory, motor and circulatory functions are intact after stabilization, and the patient is given 50 mcg of intranasal fentanyl en route to the emergency department.

Types of Fractures

Fractures are classified as open (compound) or closed (simple). Open fractures, in addition to the compromised integrity of the bone, result in an open wound in the skin, and thus an increased risk of infection. Other, more specific types of fractures include:

Complete fractures involve separation of bone ends at the fracture site. In severe cases, these bone ends may be displaced or angulated from one another.

Incomplete fractures are simple cracks in the bone, with bone ends not completely separated.

Transverse fractures run perpendicular to the long axis of the bone.

Linear fractures run parallel to the long axis of the bone.

Oblique fractures run diagonal to the long axis of the bone.

Comminuted fractures result in multiple bone fragments, usually from fractured bone ends being driven together.

Green stick fractures are incomplete fractures of incompletely ossified bones, usually in small children. The side of the bone where force was applied usually remains intact, but the opposite side of the bone erupts in multiple fracture sites, much like breaking a green stick.

Spiral fractures usually result from twisting forces, and produce a diagonal fracture line that may spiral around the shaft of the bone. This type of fracture is not uncommon in professional athletes such as football or soccer players, who often plant their feet and change directions while running at full speed.

Upon arrival at the emergency department, the attending physician listens to the EMT’s report, taking particular note that the patient was able to bear weight for 20 feet. He removes the pillow splint and carefully palpates the distal 6 cm of the tibia and medial malleolus, and the distal 6 cm of the fibula and lateral malleolus. Finding no deformity or significant point tenderness, he asks the patient to walk to the other side of the examination room. The patient complies, wincing as he does, but bearing weight on the injured ankle. The doctor says he believes the patient suffered a simple sprain, and that x-rays will not be necessary. He prescribes an NSAID pain reliever and a regimen of RICE (rest, ice, compression, elevation) and discharges the patient home with a set of crutches. Much to the EMTs’ surprise, the patient leaves the emergency department before they have completed their run report.

Conclusion

While the physician’s assessment and subsequent discharge of the patient may have seemed cavalier to the EMTs, it was actually based upon sound scientific evidence. The Ottawa Ankle and Foot Rules¹ are a set of clinical assessment guidelines designed to limit the number of unnecessary x-rays in emergency departments. These clinical guidelines are nearly 100% sensitive at determining the need for ankle or foot radiographs, and have been estimated to reduce the number of unnecessary x-rays by as much as 40%, thus conserving finite resources and bed space and easing ED overcrowding. Similar guidelines have been developed for determining the need for radiography in knee injuries.²

While teaching these guidelines to patients has not resulted in fewer unnecessary emergency department visits,³ it is conceivable they may one day be adopted by EMS providers. While the EMTs in the scenario witnessed the application of the rules in the ED, it is not uncommon to find them implemented outside the hospital, particularly at sporting events where certified athletic trainers have been trained in their application. Many of these trainers have adopted the Ottawa Rules to their own use, much like many EMS systems have adopted NEXUS criteria as the foundation of their selective spinal immobilization protocols.

References

1. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 21(4): 384–90, Apr 1992.

2. Stiell IG, Greenberg GH, Wells GA, McDowell I, Cwinn AA, Smith NA, Cacciotti TF, Sivilotti MLA. Prospective validation of a decision rule for use of radiography in acute knee injury. JAMA 275: 611–615, 1996.

3. Blackham JE, Claridge T, Benger JR. Can patients apply the Ottawa ankle rules to themselves? Emerg Med J 25(11): 750–751, 2008.

Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 14 years as a field paramedic, critical care transport paramedic, field supervisor and educator. He is the author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between and the popular blog A Day in the Life of An Ambulance Driver.

William E. (Gene) Gandy, JD, LP, NREMT-P, has been a paramedic and EMS educator for more than 30 years. He has implemented a two-year associate’s degree paramedic program for a community college, served as both a volunteer and paid paramedic, and practiced in both rural and urban settings. He lives in Tucson, AZ.