1. Introduction to Emergency Medical Care 1
Advance Preparation
Prepare anatomy models for demonstration.
Research related multimedia links for illustration purposes.
Prepare splinting supplies for demonstration.
Invite assistant instructors and programmed patients to assist with psychomotor sessions.

2. OBJECTIVES
30.1 Define key terms introduced in this chapter. Slides 11–12, 19–20, 22–23, Describe the anatomy of elements of the musculoskeletal system. Slides 11– Associate mechanisms of injury with the potential for musculoskeletal injuries. Slide 18
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3. OBJECTIVES
30.4 Describe the four types of musculoskeletal injury (fracture, dislocation, sprain, and strain) and define open and closed extremity injuries. Slides 19– Discuss the assessment of musculoskeletal injuries, including compartment syndrome. Slides 22–24
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4. OBJECTIVES
30.6 Discuss the general care of musculoskeletal injuries. Slides 26– Discuss specific considerations for splinting. Slides 28–37
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5. OBJECTIVES
30.8 Discuss considerations in the assessment and management of specific types of injuries, including shoulder girdle injuries, pelvic injuries, hip dislocation, hip fracture, femoral shaft fracture, knee injury, tibia or fibula injury, ankle or foot injury. Slides 39–52

6. MULTIMEDIA Slide 53 Hip Fractures Video
Slide 54 Immobilizing a Long Bone Video
These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.

7. Understanding bones, muscles, and other elements of the musculoskeletal system
Understanding general guidelines for emergency care of musculoskeletal injuries
continued

8. Purposes and general procedures for splinting
Assessment and care of specific injuries to the upper and lower extremities

9. Topics Musculoskeletal System General Guidelines for Emergency Care
Emergency Care of Specific Injuries
Planning Your Time: Plan 100 minutes for this chapter.
Musculoskeletal System (20 minutes)
General Guidelines for Emergency Care (40 minutes)
Emergency Care of Specific Injuries (40 minutes)
Note: The total teaching time recommended is only a guideline.

10. Musculoskeletal System
Teaching Time: 20 minutes
Teaching Tips: Use anatomical models (a skeleton) to demonstrate A&P. Obtain a bone from a butcher or supermarket to help demonstrate bone anatomy. This section lends itself well to multimedia presentations. Use graphics to illustrate A&P as well as various types of injuries.

11. Components of Musculoskeletal System
Bones
Joints
Muscles
Cartilage
Ligaments
Tendons
Point to Emphasize: The musculoskeletal system is composed of all the bones, joints, and muscles of the body, as well as cartilage, tendons, and ligaments.
Knowledge Application: Dissect an animal leg. Contact a butcher and obtain animal extremities. Dissect and discuss anatomy and physiology.

12. Physiology of Musculoskeletal System
Bones: framework
Joints: bending
Muscles: movement
Cartilage: flexibility
Ligaments: connect bone to bone
Tendons: connect muscle to bone
Point to Emphasize: Joints are the places where bones articulate. They are a critical element in the body’s ability to move.
Discussion Topic: Describe the functions of bones.

13. Bones Formed of dense connective tissues
Vascular and susceptible to bleeding on injury
Point to Emphasize: Bones provide the body with structure, store salts and metabolic materials, and provide a site for the production of red blood cells.
Class Activities: Distribute a blank anatomy diagram of the musculoskeletal system. Have students label the major bones and joints. Take apart a skeleton anatomy model. Have students work in groups to put the skeleton back together. Discuss articulation and joints.
Knowledge Application: Describe an injury. Ask students to classify the type of injury that you are describing.

14. Shapes of Bones
Irregular
Long
Short
Flat

15. Self-Healing Nature of Bone
Break causes soft tissue swelling and a blood clot in the fracture area
Interruption of blood supply causes the bone section to die
Cells further from fracture divide rapidly forming tissue that heals the fracture and develops into new bone
Point to Emphasize: Because of the self-healing property of bones, it is very important for a broken bone to be immobilized quickly and to remain immobilized to heal properly.
Discussion Topic: Explain why it is important to immobilize a broken bone properly.
Critical Thinking: We discussed the need to immobilize bone to promote proper healing. What is the role of the EMT with regard to this concept?

16. Muscles, Cartilage, Ligaments, and Tendons
Point to Emphasize: Muscles, cartilage, ligaments, and tendons are the tissues that cause movement of body parts or organs.
Talking Points: Muscles are the tissues or fibers that cause movement of the body. Cartilage is connective tissue that covers the outside of the bone ends. Tendons are bands of connective tissue that bind muscles to bones.
Discussion Topic: Describe the functions of muscles, ligaments, and tendons.
Knowledge Application: Use a programmed patient or model. Have students work in small groups and use the model to present anatomical features of the musculoskeletal system.

17. General Guidelines for Emergency Care
Teaching Time: 40 minutes
Teaching Tips: Use specific examples (multimedia graphics and illustrations) of the various forces that cause musculoskeletal injuries. Although it is important to differentiate among the various types of injuries, make it clear that often a specific diagnosis is impossible and that the EMT should treat with the worst-case scenario in mind. Relate common signs and symptoms to your discussion of anatomy and physiology. How does disruption of function translate into signs and symptoms? Demonstrate treatment steps with a programmed patient. Have proper splinting equipment on hand and allow students to visualize the proper methods. Use moulage to simulate various types of wounds. Demonstrate treatment.

18. Mechanisms of Musculoskeletal Injury
Direct force
Indirect force
Twisting (rotational) force
Point to Emphasize: There are three types of mechanisms that cause musculoskeletal injuries: direct force, indirect force, and twisting force.
Talking Points: Direct force is a person being struck by an automobile. Twisting or rotational force can cause stretching or tearing of muscles and ligaments. Indirect force causes injuries to the body away from the actual impact and can be more serious than the original injury.
Discussion Topic: Describe the three mechanisms that cause musculoskeletal injuries.
Knowledge Application: Have students work in small groups. Hand out sticks and have each group present an example of a specific force that causes musculoskeletal injury. Have groups discuss their examples.

19. Injury to Bones and Connective Tissue
Fracture: any break in a bone (open or closed)
Comminuted—broken in several places
Greenstick—incomplete break
Angulated—bent at angle
Dislocation: “coming apart” of a joint
Points to Emphasize: There are four types of musculoskeletal injury: fracture, dislocation, sprain, and strain. A closed extremity injury is one in which the skin has not been broken. An open extremity injury is one in which the skin has been broken.
continued

20. Injury to Bones and Connective Tissue
Sprain: stretching and tearing of ligaments
Strain: overstretching of muscle
Discussion Topic: Describe the four types of musculoskeletal injury.
continued

21. Injury to Bones and Connective Tissue
Not all injuries can be confirmed as a fracture in the field
Splinting an extremity with a suspected fracture helps prevent blood loss from bone tissues
Talking Points: Signs and symptoms of a fracture should be treated as the worst case in patients.

22. Assessment: Musculoskeletal Injuries
Rapidly identify and treat life-threatening conditions
Be alert for injuries besides grotesque wound
Pain and tenderness
Deformity and angulation
Point to Emphasize: Assessment always should focus on identifying life threats. It often is difficult to determine the exact type of musculoskeletal injury. EMTs always should assume a fracture.
Talking Points: Assessment will involve your sight, hearing, and touch. Compartment syndrome results from increased swelling in the muscle compartment/area, which progresses to cellular death from loss of blood flow. The best treatment if it is suspected is to treat the underlying injury; i.e., splint the wound.
continued

23. Assessment: Musculoskeletal Injuries
Grating (crepitus)
Swelling
Bruising
Exposed bone ends
Nerve/blood vessel compromise (decreased CMS)
Compartment syndrome
Class Activity: Facilitate a discussion about what other, more life-threatening injuries may be present in a musculoskeletal injury.
Knowledge Application: Describe signs and symptoms of a musculoskeletal injury. Ask the class to prioritize assessment and treatment. Emphasize treatment of primary survey problems.

24. Six P’s of Assessment Pain or tenderness Pallor (pale skin)
Parasthesia (pins and needles)
Pulses diminished or absent
Paralysis
Pressure
Discussion Topic: Describe the signs and symptoms of musculoskeletal injuries. Include the “six P’s.”
Class Activity: Have students work in pairs to assess each other’s circulatory, sensory, and motor functions.
Knowledge Application: Discuss the assessment of a musculoskeletal injury. What are the immediate priorities? What signs might indicate an isolated injury?

25. Think About It
Do my patient’s musculoskeletal injuries add up to serious multiple trauma?
Does my patient have circulation, sensation, and motor function distal to the suspected fracture or dislocation?
Talking Points: Remind students that, depending on the situation, musculoskeletal injuries can appear in multiple sites. Lead them to realize how important checking circulation, sensation, and motor function is to assessing a patient.

26. Treatment: Musculoskeletal Injuries
Take standard precautions
Perform primary assessment
Take spinal precautions, if necessary
continued

27. Treatment: Musculoskeletal Injuries
Splint any suspected extremity fractures after treating life-threatening conditions
Cover open wounds with sterile dressings
Point to Emphasize: Effective splinting immobilizes adjacent joints and bone ends and minimizes the movement of disrupted joints and broken bone ends.
Critical Thinking: How might a pelvic fracture or a femur fracture actually be a life-threatening injury?

28. Advantages of Splinting
Minimizes movement of disrupted joints and broken bone ends
Prevents additional injury to soft tissues (nerves, arteries, veins, muscles)
Decreases pain
Minimizes blood loss
Can prevent a closed fracture from becoming an open fracture
Talking Points: For any splint to be effective, it must immobilize adjacent joints and bone ends. A deformed extremity can be realigned if necessary to restore effective circulation or fit it into a splint. Effective splinting may require some ingenuity. Splints often come in either rigid, formable, or traction style.

29. Principles of Splinting
Care for life-threatening problems first
Expose injury site
Assess distal CSM
Align long-bone injuries to anatomical position
Do not push protruding bones back into place
Discussion Topic: Discuss the general rules for immobilization as they apply to splinting a possible fracture.
continued

30. Principles of Splinting
Immobilize both injury site and adjacent joints
Choose splinting method based on severity of condition and priority decision
Apply splint before moving patient to stretcher
Pad voids

31. Realigning Deformed Extremity
Assists in restoring effective circulation to extremity and to fit it to splint
If not realigned, splint may be ineffective, causing increased pain and possible further injury
continued

32. Realigning Deformed Extremity
If not realigned, increased chance of nerves, arteries, and veins being compromised
Increased pain is only momentary

33. Hazards of Splinting
“Splinting patient to death”—splinting before life-threatening conditions addressed
Not ensuring ABC’s
Too tight—compresses soft tissues
Too loose—allows too much movement
Splinting in deformed position

34. Treatment: Splinting Long Bone and Joints
Select splint appropriate to injury
Standard precautions
Manually stabilize injury site
continued

35. Treatment: Splinting Long Bone and Joints
Assess circulation, sensation, and motor function
Realign injury if deformed or if distal extremity is cyanotic or pulseless
continued

36. Treatment: Splinting Long Bone and Joints
Measure or adjust splint; move it into position
Apply and secure splint to immobilize injury site, adjacent joints
Reassess CSM distal to injury
Knowledge Application: Use programmed patients and moulage to simulate various musculoskeletal injuries. Have teams of students practice assessment and treatment.

37. Treatment: Traction Splint
Talking Points: A traction splint counteracts the muscle spasms and greatly reduces the pain associated with a long-bone femur fracture. Steps for using traction splint: (1) Take Standard Precautions. Expose area to be splinted. (2) Manually stabilize leg. Apply manual traction. (3) Assess CSM distal to injury. (4) Adjust splint to proper length. Position it at or under injured leg. (5) Apply proximal securing device (ischial strap). (6) Apply distal securing device (ankle hitch). (7) Apply mechanical traction. (8) Position and secure support straps. (9) Re-evaluate proximal and distal securing devices. Reassess CSM distal to injury. (10) Secure patient’s torso and traction splint to long spine board to immobilize hip and prevent movement of splint.

38. Emergency Care of Specific Injuries
Teaching Time: 40 minutes
Teaching Tips: Use multimedia graphics and anatomical models to demonstrate the different injuries that you are discussing. Have various types of splinting equipment on hand. Demonstrate examples of splints and immobilization devices. Teach creativity. Compare commercially available splints to improvised splints. Do not focus on one particular type of splint. Invite a wilderness EMT instructor to class. Most wilderness classes stress improvised devices. Such instructors will lend great insight to splinting.

39. Shoulder Girdle Injuries
Assessment
Pain in shoulder
Dropped shoulder
Severe blow to back over scapula
Discussion Topics: Describe how you would use a sling and swathe. List the steps of application.
continued

40. Shoulder Girdle Injuries
Treatment
Assess distal CSM
Use sling and swathe
Do not attempt to straighten or reduce
Reassess distal CSM
Point to Emphasize: EMTs should use a sling and swathe to immobilize an injury to the shoulder girdle.
Knowledge Application: Have students work in pairs to practice applying a sling and swathe. Use a programmed patient to simulate various musculoskeletal injuries.

41. Forearm, Wrist, and Hand Injuries
Signs
Forearm: deformity and tenderness
Wrist: deformity and tenderness
Hand: deformity and pain; dislocated fingers

42. Splinting Forearm, Wrist, and Hand Injuries
Padded rigid splint
From elbow past fingertips
Roll of bandage placed in hand
Sling and swathe
Discussion Topic: Compare and contrast soft splints to rigid splints. How might their uses differ?
continued

43. Splinting Forearm, Wrist, and Hand Injuries
Soft splint
Roll of bandage placed in hand
Tie forearm, wrist, and hand into fold of one pillow or between two pillows
Tape finger to adjacent uninjured finger

44. Pelvic Injuries Assessment Pain in pelvis, hips, or groin
Pain when pressure applied
Cannot lift legs
Lateral rotation of foot
Unexplained pressure in bladder
Point to Emphasize: Any force that is strong enough to fracture the pelvis also can cause injury to the spine and other vital internal structures.
Knowledge Application: Use a programmed patient to simulate various musculoskeletal injuries. Practice assessment and apply different types of splints and immobilization devices.
continued

45. Pelvic Injuries Treatment Move patient as little as possible
Determine CSM distal to injury
Straighten lower limbs to anatomical position
Stabilize lower limbs
Assume spinal injuries
Treat for shock
Point to Emphasize: Consider using a pelvic wrap, pneumatic anti-shock garments, or a pelvic binder to immobilize an unstable pelvis.

46. Hip Dislocation/Fracture
Assessment
Anterior hip dislocation
Posterior hip dislocation
Rotation of leg and foot
Pain and unable to stand
continued

47. Hip Dislocation/Fracture
Treatment
Assess distal CSM
Move patient onto spine board
Immobilize limb with pillows and blankets
Secure patient to spine board
Reassess distal CSM
Point to Emphasize: Be sure to assess for distal circulatory, sensory, and motor functions before and after immobilizing a hip dislocation. To immobilize a hip fracture, consider using padded boards, binding the legs together, or applying pneumatic anti-shock garments.

48. Femoral Shaft Fracture
Assessment
Intense pain
Possibly open fracture
Injured limb may be shortened
Treatment
Control bleeding
Assess distal CSM
Apply traction splint
Reassess distal CSM
Treat for shock
Point to Emphasize: Use a traction splint to immobilize isolated femoral shaft fractures.

49. Knee Injury Assessment Treatment Pain and tenderness Swelling
Deformity with swelling
Treatment
Assess distal CSM
Immobilize in current position
Reassess distal CSM
Point to Emphasize: Other musculoskeletal injuries require creativity and utilization of specific immobilization equipment. Always remember the basic principles of splinting.
Knowledge Application: Set up a splinting “round robin.” Prepare stations for different types of injuries and immobilization devices. Have groups of students rotate through the stations.

50. Tibia/Fibula Injury Assessment Treatment Pain and tenderness Swelling
Possible deformity
Treatment
Air inflated splint
Two-splint method
Single splint with ankle hitch
Discussion Topic: Discuss how to improvise a splint. What everyday items might you use?

51. Ankle/Foot Injury Assessment Pain Swelling Possible deformity
continued

52. Ankle/Foot Injury Treatment Assess distal CSM Stabilize limb Lift limb
Place cravats under ankle
Lower limb into pillow
Tie pillow around ankle
Apply ice pack as needed
Discussion Topic: Describe the assessment findings and immobilization techniques for the following types of injuries: shoulder girdle injury, pelvic fracture, hip dislocation/fracture, femoral shaft fracture, knee injury, tibia/fibula fracture, ankle/foot injury.
Class Activity: Improvise splints. Assemble common household items and ask students to create splints.
Critical Thinking: Discuss the concept of “splinting to death.” When might it actually be hazardous to the patient to complete a thorough splinting of all possible fractures?

53. Click here to view a video on the subject of hip fractures.
Hip Fractures Video
Video Clip
Hip Fractures
What happens during a hip dislocation?
How is the type of hip fracture determined?
What type of damage can occur as a result of a fractured hip?
Discuss the management of a potential hip fracture in the prehospital environment.
Click here to view a video on the subject of hip fractures.
Back to Directory

54. Immobilizing a Long Bone Video
Video Clip
Immobilizing a Long Bone
What are signs and symptoms of a long bone fracture or dislocation?
Discuss characteristics of an effective splint.
What are some types of splints that can be used on a long bone injury?
When should you use a traction splint?
Click here to view a view a video on the subject of splinting a long bone injury.
Back to Directory

55. Chapter Review

56. Chapter Review
Bones bleed. Fractures cause blood loss within the bone.
Splinting of long bone fractures involves immobilizing adjacent joints.
Splinting protects the patient from further injury.
continued

57. Chapter Review
You may need to be creative while splinting. There are many correct ways to splint the same extremity.
Injuries to bones and joints should be splinted prior to moving the patient.
continued

58. Chapter Review
If patient has multiple trauma or appears to have shock do not waste time splinting individual fractures. Place patient on long spine board and secure limbs to board. Splint individual fractures en route if time and priorities allow.

59. Remember
Bones, joints, muscles, cartilage, tendons, and ligaments make up the musculoskeletal system.
Bones provide the body with structure, store metabolic materials, and produce red blood. Joints are the places where bones articulate to create movement.
continued

60. Remember
Fractures, dislocations, sprains, and strains are musculoskeletal injuries that are caused by direct force, indirect force, and twisting force. Injuries should be splinted prior to moving the patient.
continued

61. Remember
A closed extremity injury is one in which the skin has not been broken. An open extremity injury is one in which the skin has been broken.
Pelvic fractures and femoral shaft fractures often indicate more severe internal injuries.
continued

62. Remember
EMTs must learn specific techniques for immobilizing particular injuries but at the same time must foster creativity while applying the general rules of splinting.

63. Questions to Consider
Have I fully addressed life threats and maintained my priorities even in the presence of a grossly deformed extremity?
Does the patient have an injury that requires splinting?
Talking Points: Remind students that they need to use their senses of sight, touch, and hearing during their assessment of patients with musculoskeletal injuries. They will need to look past obvious signs and probe for multiple injuries in order to make a complete assessment of the patient.
continued

64. Questions to Consider
Does the patient have multiple fractures, multiple trauma, or shock?
Does the patient have adequate CSM distal to the musculoskeletal injury?
Should I align the angulated extremity fracture?

65. Critical Thinking
Patients who suffer fractures can be in extreme pain. Pain can cause anxiety and elevated pulse rates. How could you differentiate between a patient with a rapid pulse and anxiety from pain versus a patient with rapid pulse and anxiety from shock?
Talking Points: Remind students that they should always be looking for the signs of shock in any primary assessment.

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