LESSON 18 INJURIES TO MUSCLES AND BONES

Introduction Trauma patients often have considerable musculoskeletal injuries With significant mechanisms of injury, bones may fracture and joints may be injured Injuries may result in pain, disability and life-threatening bleeding

Musculoskeletal System Review Bones Muscles Tendons Ligaments

Primary Functions of Musculoskeletal System Provide shape and support for body Muscles acting on bones allow movement Bones protect vital internal organs

Types of Muscles Skeletal muscles  voluntary Smooth muscles  involuntary Cardiac muscle  involuntary All muscle activity controlled by nervous system

Mechanisms of Injury to Musculoskeletal System Direct force: force applied directly to body Indirect force: force transferred from original body site along an extremity to another point Twisting forces: part of body forced to move in unnatural direction

Factors Involved in Injuries The greater the force: The more likely the injury Fracture/Joint dislocation severity more likely Patient’s age and health status

Types of Musculoskeletal Injuries EMRs need not determine type of musculoskeletal injury: Fractures Dislocations Sprains Muscle injuries

Fractures Bone may be completely broken or only cracked Closed fracture  skin not broken Open fracture  open wound at site

Dislocations

Dislocations (continued) One or more bones at joint displaced from normal position Ligaments holding bone are torn Result from strong forces Sometimes accompanied by bone fractures or other injuries Can be very painful

Dislocations (continued) Patient cannot use joint due to pain or structural damage Serious bleeding may result Nearby nerves may be injured With severe dislocation, joint or limb will look deformed

Sprains Joint injury involving ligament stretching and tearing Typically occur when joint is overextended Can be mild or severe Ankles, knees, wrists, fingers most common Considerable swelling often occurs rapidly

Muscle Injuries Strains, contusions, cramps Usually less serious than fractures and joint injuries Many causes

Recognizing Musculoskeletal Injury Sometimes injury type is obvious Often you will recognize musculoskeletal injury if present Emergency care is same regardless of injury type Usually not life-threatening May be serious and result in pain and disability

Assessment of Musculoskeletal Injuries Perform standard assessment Ask patient what happened and what was felt If large forces involved, consider potential for spinal injury Expose injury site carefully Amount of pain and swelling not indicator of injury severity Immediate medical treatment if no circulation or possible nerve damage

Assess for Circulation, Sensation and Movement (CSM) Below the Injury Site Check pulse below injury Check skin color and temperature Touch fingers or toes Does patient feel touch, tingling sensation, numbness? Have patient wiggle fingers or toes

Signs and Symptoms of Musculoskeletal Injury

Signs and Symptoms of Musculoskeletal Injury (continued) Pain and tenderness Abnormal sensation (numbness, tingling) Inability to move area Joint locked into position Impaired function or circulation Difference in temperature from opposite extremity

Preventing Movement Movement causes injury, pain, swelling Bone movement further injures soft tissues Movement generally increases blood flow - may increase internal bleeding and swelling Manually stabilize or splint injured area

Emergency Care of Musculoskeletal Injuries Perform standard patient care Control any life threats Allow patient to be in position of comfort Cover open wounds with sterile dressing Apply cold pack with skin barrier Don’t replace protruding bones

Emergency Care of Musculoskeletal Injuries (continued) Stabilize injured extremity manually Support above and below injury If appropriate, splint extremity Follow local protocol for oxygen With traumatic amputation of a body part, care for amputated part after stabilizing patient

Splinting

Splinting Movement may worsen musculoskeletal injury and cause more pain Splint injured arm or leg if risk of area being moved (unless help expected quickly) Always splint an extremity before patient is transported

Splinting (continued) Helps prevent further injury Reduces pain Minimizes bleeding and swelling

Types of Splints Rigid splints Soft splints Air splints (inflatable splints) Pneumatic splints Anatomic splints Improvised splints

Rigid Splint Board Plastic or metal Rolled newspaper or magazine Thick cardboard

Soft Splint Pillow Folded blanket or towel Triangular bandage folded into sling

Anatomic Splint Bandage injured leg or finger to uninjured one

Commercial Splints

Securing Splints Use bandages, strips of cloth, Velcro Use knots that can be untied Don’t secure with tape to skin

Guidelines for All Splints Dress open wounds Splint only if it doesn’t cause more pain Splint in position found Immobilize entire area (joints above and below injury) Pad between splint and skin Assess CSM before and after splinting Put splints on both sides of fracture if possible Apply cold pack to injury around splint

Guidelines for Slings Use sling to prevent movement and to elevate extremity Splint injury first If you splint injury in position found and this position makes use of sling difficult  do not use sling

Guidelines for Slings (continued) Do not move arm into position for sling if it causes pain A cold pack can be used inside sling Do not cover fingers inside sling

Skill: Applying Arm Sling and Swathe

Secure point of bandage at elbow

Position triangular bandage

Bring lower end of bandage to opposite side of neck

Tie the ends

Tie swathe bandage over sling and around chest

Shoulder Injuries Involve clavicle, scapula or joint structures Clavicle is most frequently fractured bone Scapula fractures are rare Shoulder dislocations are common

Splinting Shoulder Injuries Goal is to stabilize area from trunk to upper arm Use soft splint; do not move extremity Assess for circulation, sensation and movement

Splinting Shoulder Injuries (continued) Pad hollow between body and arm Apply sling and swathe to support and immobilize arm – if this causes pain use larger pillow

Upper Arm Injuries Immobilize humerus fractures with rigid splint Treat fractures near shoulder with soft splint

Splinting Upper Arm Injuries Stabilize bone between shoulder and elbow Assess circulation, sensation, movement in hand and fingers Apply rigid splint along outside of arm

Splinting Upper Arm Injuries (continued) Tie splint above injury and at elbow Support wrist with sling and wide swathe If it causes pain to raise wrist for a sling, use long rigid splint

Elbow Injuries Sprains and dislocations are common Fractures occur above or below elbow Patient unable to move joint

Splinting Elbow Injuries If elbow bent, apply rigid splint from upper arm to wrist If more support needed, use sling at wrist and swathe around chest

Splinting Elbow Injuries (continued) If elbow straight, apply rigid splint from upper arm to hand If more support needed, use swathes around chest and upper arm and lower arm and waist

Skill: Splinting a Forearm

Support arm and check circulation

Position arm on rigid splint

Secure splint Put splinted arm in sling and swathe

Check circulation

Wrist Injuries Sprains Fractures

Splinting Wrist Injuries Goal is to stabilize from forearm to hand Soft splint and sling often sufficient Rigid splint provides more support Assess circulation, sensation, movement in hand and fingers

Splinting Wrist Injuries (continued) Apply rigid splint on palm side of arm from forearm past fingertips Tie above and below wrist Leave fingers uncovered Support forearm and wrist with sling and apply binder around upper arm and chest

Hand Injuries May be injured by direct blow Fractures occur when patient punches something with closed fist

Splinting Hand Injuries Goal is immobilization of hand – use soft or rigid splint Place roll of gauze in palm Bandage entire hand  leave fingers exposed if possible to check CSM Place rigid splint on palm side of hand; pad between hand and splint Support further with sling and swathe

Finger Injuries Fractures and dislocations Often a splint is not required Use rigid splint or anatomic splint

Splinting Finger Injuries Use soft splint if finger cannot be straightened without pain Don’t manipulate finger into normal position Use rigid splint, secured with tape  or anatomic splint by taping finger to adjoining finger with gauze in between

Lower Extremity Injuries Larger forces are typically involved – forces may also cause spinal injury Assess patient without moving extremity Femur fracture can damage femoral artery and cause life-threatening bleeding

Hip and Pelvis Injuries Fractures and dislocations Hip fracture: fracture of top part of femur Fractures more common in elderly due to osteoporosis Bleeding and pain may be severe Dislocations can occur at any age: Falls Vehicular crashes Blows to body

Splinting Hip and Pelvis Injuries Do not move patient Immobilize leg and hip in position found Pad between legs and bandage together (unless this causes more pain) Treat for shock but do not elevate legs

Upper Leg Injuries Femur fractures are serious Severe pain and shock may occur Keep patient from moving Rigid splint unnecessary if patient is lying down with leg supported by ground Use folded blankets or coats to immobilize leg in position found

Splinting Upper Leg Injuries Anatomic splint Rigid splints

Splinting Upper Leg Injuries (continued) Check circulation and sensation in foot and toes Put rigid splint on each side of leg Pad body areas and voids Inside splint should extend from groin past foot Outside splint should extend from armpit past foot

Anatomic Splinting of Leg Injuries Gently slide 4 or 5 bandages under both legs  but not over injury Put padding between legs Do not move injured leg Gently slide uninjured leg next to injured leg Tie bandages Check circulation again

Traction Splint for Femur Fractures Traction splint maintains continual pull on femur to keep bone ends in normal position EMRs may assist other EMS personnel

Knee Injuries Sprains Dislocations Caused by: Sports injuries Motor vehicle crashes Falls Femur, tibia or fibula fractures are indistinguishable from knee injuries

Splinting Knee Injuries Splint in position found Apply soft splint by rolling blanket or placing pillow around knee If knee straight, make anatomical splint

Splinting Knee Injuries (continued) If possible, put rigid splint on both sides of leg Pad body areas and voids Check circulation and sensation in foot and toes first and periodically after splinting

Splinting Knee Injuries (continued) If knee is straight, apply 2 splints along both sides of knee If knee is bent, splint in position found Tie splints with cravats or bandages

Lower Leg Injuries Commonly caused by: Sports Motor vehicle crashes Falls Either or both bones of lower leg can be fractured

Lower Leg Injuries (continued) Rigid splint applied the same as for knee injury 3-sided cardboard splint can be used

Skill: Splinting the Leg (Anatomic)

Check circulation Gently slide 4 to 5 strips of bandages under both legs

Pad between legs

Gently slide uninjured leg next to injured leg

Tie bandages and check circulation

Ankle Injuries Sprain may occur when foot is forcefully twisted to one side Fractures or dislocations Often involve torn ligaments and nerve or blood vessel damage

Splinting Ankle Injuries Soft splint usually best Gently remove the shoe to assess circulation, sensation, movement in toes Tie pillow around foot and lower leg For minor ankle injury not requiring splinting, elastic roller bandage may be used for compression

Applying a Figure-8 Bandage to the Ankle Anchor starting end of bandage Turn bandage diagonally across top of foot and around ankle, and bring bandage around in a figure-8 Continue with overlapping figure-8 turns Fasten end of bandage with clips, tape or safety pins

Foot Injuries Commonly caused by: Direct blows Falls Involve almost any bone or ligament of foot Treat same as ankle injuries Toe fractures can be very painful

Splinting Foot Injuries Usually no splinting required Use pillow splint as for ankle injury if: Toe is significantly bent More than 1 toe involved Foot is very painful

Rib Fractures Typically caused by blunt trauma to chest More common in lower ribs and along side Cause severe pain, discoloration, swelling Pain often sharper upon breathing in Patient may breathe shallowly and hold or support area

Splinting Rib Injuries Goal is primarily supportive Have patient sit or stand in position for easy breathing Support ribs with pillow or soft padding loosely bandaged over area and under arm Immobilize arm with sling and swathe Monitor breathing