Musculoskeletal Injuries

Musculoskeletal Injuries
Chapter 22 Musculoskeletal Injuries Instructor Preparation Always prepare for lectures by reading the text and reviewing presentations. As an instructor it is very important that you familiarize yourself with the information in the text and the presentation. You must be familiar with the flow of the slides in order to advance through the lecture without getting ahead of the presentation. Be prepared to engage your students by asking them questions and encouraging creative discussion. EMR Complete: A Worktext Daniel Limmer Copyright ©2011 by Pearson Education, Inc. All rights reserved.

OBJECTIVES DIRECTORY Define key terms introduced in this chapter Describe the common types of force that cause musculoskeletal injuries. 13 Differentiate between open and closed musculoskeletal injuries. 12 Differentiate between the terms strain, sprain, dislocation, and fracture. 14 Describe the typical findings associated with musculoskeletal injuries Explain the principles of caring for patients with musculoskeletal injuries The objectives for this chapter meet and exceed the National EMS Education Standards for the EMR level. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.

OBJECTIVES DIRECTORY Given a variety of scenarios involving patients with musculoskeletal injuries, apply the principles of splinting Demonstrate the application of a variety of splints, such as: 29-50 Soft splints Rigid splints Traction splints Circumferential splints Improvised splints The objectives for this chapter meet and exceed the National EMS Education Standards for the EMR level. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation. 3

OBJECTIVES DIRECTORY Recognize potential complications of musculoskeletal injuries, including hemorrhage and damage to nerves and blood vessels. 11, 25-26, 45-46 Demonstrate the assessment and management of patients with amputations The objectives for this chapter meet and exceed the National EMS Education Standards for the EMR level. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation. 4

MULTIMEDIA DIRECTORY Slide 15 Information about Osteoporosis Video Slide 36 Long Bone Injuries and Splints Video Slide 37 Application of a Sager Splint 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.

TOPICS The Musculoskeletal System
EMR Patient Assessment: Musculoskeletal Injuries EMR Emergency Care: Musculoskeletal Injuries Principles of Splinting Splinting Materials EMR Patient Assessment and Emergency Care: Specific Circumstances Amputations Planning Your Time Plan 150 minutes for this chapter as follows: The Musculoskeletal System (15 minutes) EMR Patient Assessment: Musculoskeletal Injuries (15 minutes) EMR Emergency Care: Musculoskeletal Injuries (30 minutes) Principles of Splinting (30 minutes) Splinting Materials (15 minutes) EMR Assessment and Emergency Care: Special Circumstances (30 minutes) Amputations (15 minutes) Note: The total teaching time recommended is only a guideline.

INTRODUCTION Orthopedic injury $250 billion annually Talking Points
An orthopedic injury is an injury to the skeletal system and/or associated muscles, joints, tendons, and ligaments. According to the American Academy of Orthopedic Surgeons, musculoskeletal injuries cost $250 million dollars annually in the United States. These injuries account for nearly 150 million lost days of work and 20 million missed days of school. Although a broken bone is typically not life threatening, this type of injury can have a serious impact on the patient’s ability to function in a normal capacity. As an EMR, you will play a key role in helping your patient overcome an orthopedic injury. Careful and compassionate actions in the prehospital stage will help maximize the potential for a positive outcome. Your responsibility is to care for the patient in a manner that minimizes the potential for additional injury.

Case Study: The Call Environment Cold January day
Snow has accumulated on the ground CONTINUED

Case Study: The Call Details
You are walking down the street and see an elderly woman stumble and fall in the street She attempts to get up and falls back down She yells for help as she struggles to sit up You instruct someone to call 911 You approach the patient Case Study Discussion How do you begin your assessment? How do you think this elderly woman is feeling? Given the injury described in this scenario, what would you consider to be the immediate treatment priorities? 9

The Musculoskeletal System
Teaching Time 15 minutes Teaching Tips This section lends itself well to multimedia presentations. Use graphics to illustrate anatomy and physiology as well as various types of injuries. Use anatomical models (in particular, a skeleton) to demonstrate anatomy and physiology. Emphasize that although it is important to differentiate among the various types of injuries, a specific diagnosis may not be important. The EMR should keep the worst-case scenario in mind when treating the patient. Use specific examples or illustrations of the various forces that cause musculoskeletal injuries. Discussion Question Discuss the functions of the musculoskeletal system. Knowledge Application Label a skeleton. Assign a blank diagram of a skeleton. Have students label important structures and specific bones. Back to Topics

Back to Objectives Talking Points
The 206 bones in the human body work together with muscles and specialized connective tissues to form the musculoskeletal system. This combination of muscle and bone allows us to move and protects internal organs. The core of the body is protected by the axial skeleton while the upper and lower extremities form the appendicular skeleton. Musculoskeletal injuries can be life threatening. When a bone breaks, large vessels that often run alongside the bone may be damaged, resulting in significant bleeding (especially with the pelvis and femur). Points to Emphasize Musculoskeletal injuries are classified as open or closed. An open injury means that the skin over the bone has been broken. A closed injury means that the skin is intact. A strain occurs when muscles and tendons are overworked or stretched beyond their normal range of motion. A sprain occurs when the same forces are applied to ligaments. A dislocation occurs when one or more bones in a joint are forced out of place. A fracture means that a bone has been cracked or broken. Fractures and dislocations often occur at the same time. Back to Objectives

The Musculoskeletal System
Photo: © Edward T. Dickinson, M.D. Talking Points Musculoskeletal injuries can be classified as either open or closed. An open injury is when the skin at the injury site has been penetrated, usually by a broken bone end. A closed injury is when the skin at the injury site remains intact. Discussion Question Compare an open musculoskeletal injury to a closed injury. What are the signs of each? Knowledge Application Describe a musculoskeletal injury. Have students classify it as open or closed and explain their reasoning. Open injury Closed injury Back to Objectives

Mechanism of Injury Direct force Indirect force Twisting force
Talking Points Assess mechanism of injury to evaluate the way force was applied and to predict the type of injury. Common forces that cause injury are: Direct force—Direct impact with another object; e.g., being hit with a baseball bat or being ejected from an MVC and striking a tree Indirect force—Injury caused away from the site of impact as the force is transferred to other parts of the body; e.g., person may fall and land on his feet, but the force is transferred up the legs to the knees, hips, pelvis, and spine. Twisting force—Occurs when one part of the body is stationary as another part is twisted; e.g., an ankle is caught as the body is thrown forward. Knowledge Application Distribute sticks to small groups of students. Have each group present an example of a specific force that causes musculoskeletal injury. Have groups discuss their examples. Critical Thinking Discussion We typically think of long bones when we consider the forces that cause musculoskeletal damage. How would these forces act on irregular-shaped bones like the pelvis, ribs, or skull? Give examples of musculoskeletal injuries to each. Back to Objectives

Specific Musculoskeletal Injuries
Strain Sprain Dislocation Fracture Angulated fracture Treat them all the same Talking Points Not all musculoskeletal injuries involve broken bones. In fact, most injuries involve the soft tissue that connects bone. Since you can’t be sure if a bone is broken or if the injury only involves this tissue, assume a bone is broken in all cases and treat accordingly. Sprain—Muscles and tendons are overworked or stretched and extended beyond their normal range of motion; e.g., a football player suddenly changes direction and twists his ankle. Strain—Muscle is overextended or stretched beyond its normal range of motion; e.g., someone lifts a weight that is too heavy and “pulls a muscle.” Dislocation—Joint is disrupted (a bone that makes up a joint is moved out of place). This is extremely painful and could result in nerve and vessel injury. If not corrected, a dislocation can result in long-term loss of function or even loss of the limb itself. A dislocation can also cause fractures to the bones that make up the joint. For example, a basketball player may attempt to break his fall by outstretching his arm. As the force travels up the arm, it dislocates the shoulder. A fracture is when bone is cracked or completely broken; e.g., someone is hit in the leg with a baseball bat, and the bone is broken. – An angulated fracture is a normally straight bone that is bent due to fracture. This fracture poses a threat to nerves and vessels and is considered to be a true emergency. It is not your responsibility to determine the type of injury; all musculoskeletal injuries will be treated the same. Back to Objectives

Information about Osteoporosis
Video Clip What causes osteoporosis? What contributing factors are associated with osteoporosis? Who is most likely to be diagnosed with osteoporosis? Describe what happens to the bones of patients with osteoporosis. Discuss ways to help prevent osteoporosis. Click on the screenshot to view a video with information about osteoporosis. Back to Directory

Case Study: The Response
Patient is in the road but traffic is minimal As you approach she says, “I think I broke my leg.” Her airway is patent with no signs of difficulty breathing Skin is warm and dry with a good radial pulse Unusual angle to right lower leg CONTINUED

Case Study: The Response Cont.
She claims it hurts a lot and felt a “snap” as she fell As you wait for EMS, you offer your coat and stabilize the injury by placing your hands above and below the injury site Case Study Discussion What do you think was forgotten as part of the assessment of this elderly person? Consider what other factors are needed to complete a thorough assessment. For example, why did the patient fall? Does she have any underlying medical problems?

EMR Patient Assessment: Musculoskeletal Injuries
Teaching Time 15 minutes Teaching Tips Use graphics to illustrate major musculoskeletal injuries. Facilitate a discussion on what additional and more life-threatening injuries may be present. Relate common signs and symptoms to your discussion on anatomy and physiology. How does disruption of function translate into signs and symptoms? Discussion Question Discuss how the major forces that cause musculoskeletal trauma might impact other vital organs and structures. Knowledge Application Describe signs and symptoms of a musculoskeletal injury. Ask the class to prioritize assessment and treatment. Emphasize the treatment of problems identified during a primary assessment. Discuss the assessment of a musculoskeletal injury. What are the immediate priorities? What signs might indicate an isolated injury? Back to Topics

Talking Points Musculoskeletal injuries may easily distract you from life-threatening injuries because they can be so gruesome. Complete your primary assessment and treat life threats before addressing nonlife-threatening injuries. Consider the mechanism of injury when assessing a musculoskeletal injury patient. Think of where the force was applied and how much force was applied. Point to Emphasize Do not allow yourself to be distracted from more primary life threats because of the presence of disturbingly graphic musculoskeletal injuries. Complete a thorough patient assessment to find the most severe injury. Critical Thinking Discussion You are treating a young woman who has been struck by a car. She has an angulated lower leg fracture. You ask her if her neck or back hurts and she says, “No.” How reliable is this answer, and why?

Assessment of Musculoskeletal Injuries
Typical findings Pain Tenderness Deformity Open wounds Crepitus Loss of range of motion Swelling and discoloration Loss of sensation Loss of circulation Talking Points Typical findings for a musculoskeletal injury include: Pain at the site of impact Tenderness (or pain upon palpation) at the site of impact Deformity of the injured area Open wounds or exposed bone ends Crepitus Loss of range of motion Swelling and discoloration Loss of sensation (if a nerve is experiencing pressure or is damaged) Loss of circulation (if a vessel is being compressed or damaged) Discussion Question Describe the common signs and symptoms of musculoskeletal injury. Back to Objectives

EMR Emergency Care: Musculoskeletal Injuries
Teaching Time 30 minutes Teaching Tips Demonstrate treatment steps with a programmed patient. Allow students to visualize the proper methods. Use moulage to simulate various types of wounds. Demonstrate treatment. Knowledge Application Use programmed patients and moulage to simulate various musculoskeletal injuries. Have teams of students practice assessment and treatment. Have students work in pairs to assess each other’s circulatory, sensory, and motor functions. Review the operation of cold packs. Back to Topics

Talking Points Treatment of musculoskeletal injuries focuses on the immobilization of the injury site. Immobilizing the site keeps broken bones from moving and causing more damage. Discussion Questions Why would stabilization of a musculoskeletal injury be important? What is the purpose of immobilization? When would you assess circulation, sensation, and motor function? Why is this assessment important? Points to Emphasize When treating a person with a musculoskeletal injury, rule out other, more immediate life threats before focusing on the injury itself. Treatment priorities for musculoskeletal injuries include considering manual stabilization of the spine; stabilizing the injured extremity; exposing the wound; treating open wounds; assessing circulation, sensation, and motor function in the affected extremity; applying cold; and placing the patient in a position of comfort.

EMR Emergency Care: Musculoskeletal Injuries
Treat life threats first Consider manual stabilization of the spine Manually stabilize the site Expose Treat open wounds Assess circulation, sensation, and motor function Apply cold packs or ice Allow position of comfort Talking Points Always perform a primary assessment and treat life threats. Consider injury to underlying organs and vessels. Consider manual stabilization of the spine if the mechanism of injury suggests a possible spinal injury. Manually stabilize the site by holding above and below the site to prevent movement. Expose the injury site to assess for open wounds. Treat open wounds as you would any other soft tissue injury; do not apply pressure to exposed bone ends. Assess circulation, sensation, and motor function Apply cold packs or ice to reduce pain and swelling. Allow the patient to sit in a position of comfort while awaiting EMS. Critical Thinking Discussion In EMS we often multitask. Imagine treating a person who requires airway management but also has a severely bleeding open fracture of his leg. How would you establish the treatment priorities? In this circumstance, is treating the fracture important? Back to Objectives

Principles of Splinting
Teaching Time 30 minutes Teaching Tips There are various ways to splint a fracture. Rather than teaching specific devices, consider teaching the core principles. Demonstrate how various devices accomplish the same goal. Use multiple types of splints when practicing. Teach students to be flexible. Demonstrate splints with anatomy and physiology in mind. Use anatomical models, such as a skeleton, to illustrate how splints limit movement and immobilize bone ends. Discussion Question Discuss the reasons for applying a splint. What does splinting accomplish? Class Activity To ensure splint familiarization, review the functions of various types of splints. Compare and contrast these functions. Back to Topics

Talking Points Splinting is the process of using an object or device to restrict movement of an injured area. Although many commercial splints are available, any object that effectively immobilizes the injury site will do. Points to Emphasize “Splinting is the process of using an object or device to restrict movement of an injured area.” Reasons for splinting include stopping bone ends from damaging tissue, managing pain, controlling bleeding, and preventing circulatory and nerve damage. The basic rules for splinting are to communicate with the patient; to maintain manual immobilization; to expose the injury; to remove restricting clothing; to dress open wounds before splinting; to straighten angulated injuries (if local protocol allows); to assess circulation, sensation, and motor function; to pad the splint; to immobilize above and below the injury; and to reassess circulation, sensation, and motor function. In a long bone injury, the joint above and the joint below should be immobilized. In a joint injury, the bone above and the bone below should be immobilized.

Principles of Splinting
Reasons to splint Stopping bone ends from damaging tissue Managing pain Controlling bleeding Preventing circulatory and nerve damage Talking Points The reasons for splinting include: Stopping broken bone ends from damaging tissue—Jagged bone ends can do serious damage to tissue, vessels, nerves, and muscle. Limiting movement prevents this from taking place. Managing pain—Splinting limits movement of bone ends and helps limit muscle spasm. Control bleeding—This includes both internal and external bleeding related to a fracture. Preventing circulatory and nerve damage—Splinting keeps the injured extremity in the position of function, limiting restricted blood flow and nerve damage. Discussion Question Describe how various splints accomplish the goals of splinting. Use specific examples and demonstrate function. Knowledge Application Assign small groups particular splints. Have each group present how the splint accomplishes the goal of immobilization. Discuss specific function. Back to Objectives

Rules of Splinting Communicate with patient
Maintain manual immobilization Expose Dress open wounds Straighten angulations Assess circulation, sensation, and motor function Consider padding Immobilize above and below injury Reassess Talking Points The rules of splinting include: Communicate with patient. Typically the process of splinting will hurt; good communication will make the process easier. Maintain manual immobilization until the splint is completely applied. Manual immobilization will help limit movement. Expose the injury site to assess for open injuries. Remove jewelry and restrictive clothing. Dress open wounds before applying the splint. Straighten angulations. If the injury is severely angulated and/or has evidence of decreased blood flow below the injury (absent pulse, delayed capillary refill, cyanosis), consider gently pulling on the extremity and moving it back into normal position. Stop pulling if pain significantly increases or you feel resistance. Assess circulation, sensation, and motor function. Consider padding a splint for the comfort of the patient before applying it. Immobilize above and below injury. For a long bone injury, immobilize the joints above and below the injury site. For a joint, immobilize the bone above and below the injury site. Reassess circulation, sensation, and motor function.

Rules of Splinting Back to Objectives Talking Point
Review the steps in splinting an extremity as shown here. Discussion Question Discuss the rules of splinting. Describe the rationale for each rule. Knowledge Application Have students work in groups to list and discuss the essential steps in applying a splint. Practice communication and assign tasks. Have students use a manikin to practice straightening an angulated fracture. Critical Thinking Discussion Consider a multisystem trauma patient. How might life-threatening injuries change the priorities of splinting? Back to Objectives

Splinting Materials Back to Topics Teaching Time 15 minutes
Teaching Tips Demonstrate examples of the types of splints. Teach creativity. Compare commercially available splints to improvised splints. Invite a wilderness EMT instructor to class. Most wilderness classes stress improvised devices, so the instructors can lend great insights into improvised splinting. Back to Topics

Points to Emphasize Soft splints are made from soft materials. Examples include a pillow or a sling and swathe. Rigid splints are made from solid materials and are designed to limit movement. A traction splint is designed to pull slightly on an extremity to provide relief from muscle spasm. Air splints and vacuum splints are examples of circumferential splints. Splints may be improvised from everyday materials. Be creative as you consider the goals of splinting.

Soft Splints Sling and swathe Talking Points
Splints come in many shapes and sizes. Anything can serve as a splint as long as it immobilizes the injury. Soft splints are splints made of soft materials. An example is a sling and swathe. A sling and swathe is formed by a combination of a sling around the affected arm and triangular bandages securing the arm to the rest of the body. – First apply a sling to the arm, gently passing the sling around the arm so that the point of the triangle points to the elbow. Pass the other sides around the arm and tie behind the patient’s neck. – Next you will secure the arm to the body using cravats that wrap around the patient’s chest. Discussion Question Describe how you would use a sling and swathe. List the steps of application. Knowledge Application Have students work in pairs to practice applying a sling and swathe. Sling and swathe

Rigid Splints Made of solid object Secured to an extremity
Talking Point A rigid splint is made from a solid object such as metal, plastic, or wood and secured to an extremity to limit movement. Discussion Question Compare and contrast soft splints to rigid splints. How might their uses differ? Made of solid object Secured to an extremity

Traction Splints Talking Point A traction splint is a mechanical device that, when attached to an extremity, provides gentle pulling (traction) to help decrease pain and prevent muscle spasm. Discussion Question Discuss the type of injury that would benefit from a traction splint. Why would you choose this type of splinting device? Critical Thinking Discussion You are treating a patient with a broken femur following a motor vehicle crash. Before you apply a traction splint, what other assessment elements should you consider? Why might taking the time to apply a traction splint in this situation be ill advised? Provide gentle pulling to decrease pain and prevent muscle spasm

Circumferential Splints
Air splints Vacuum splints Talking Points Air splints are designed to be positioned around an extremity and then inflated to provide immobilization. Vacuum splints are similar to air splints in that they surround the extremity; however, air is evacuated to create a semi-rigid splint. Knowledge Application Use a programmed patient to simulate various musculoskeletal injuries. Apply different types of splints.

Improvised Splints When commercial splints are not available
Talking Points You may find yourself in a situation when a commercial splint is not available. In such cases, use improvised splints such as broom handles, sporting equipment (shin guards), card board, rolled up magazines, or pillows. Discussion Question Discuss how to improvise a splint. What everyday items might be useful? Knowledge Application Use everyday items to improvise a splint. Compare its use to that of a commercial splint. Improvised Splints When commercial splints are not available

Long Bone Injuries and Splints
Video Clip 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 are traction splints used? Click on the screenshot to view a video about long bone injuries and splints. Back to Directory

Application of a Sager Splint
Video Clip Explain the steps in applying a sager splint. Discuss when you should apply a sager splint. Why is it important to check the pulse, motor function, and sensory function before and after applying a splint? Click on the screenshot to view a video about applying a sager splint. Back to Directory

EMR Patient Assessment and Emergency Care: Specific Circumstances
Teaching Time 30 minutes Back to Topics

Teaching Tips Use a programmed patient to demonstrate injury-specific splinting techniques. Use anatomy and physiology to provide rationales for specific splinting techniques. Why do we splint a joint in place? Use multimedia graphics (X-rays, for example) to illustrate the various types of dislocations.

Upper Extremity Injuries
Talking Points Shoulder dislocations are common injuries to the upper extremity. Mechanism of injury will often be indirect pulling or pushing. The most common dislocation is when the bone of the upper arm pops forward out of the joint. With this type of dislocation, you will typically see a bulge in the anterior portion of the joint. Other signs may be a “dropped shoulder” or one shoulder that sits lower than the other. You will usually find the patient holding the arm close to his chest to prevent movement. Joint injuries are always splinted in the position found; never attempt to straighten a joint injury. To splint a shoulder injury, apply a sling and swathe. Discussion Question Discuss the pathophysiology of a dislocation. Consider why moving the extremity might be dangerous. Shoulder Sling and swathe

Elbow Rigid splint Sling and swath Talking Points Splint in the position found; never attempt to straighten the elbow. If you find the elbow straightened out, use a rigid splint. If the elbow is bent or severely deformed, consider using a sling and swath or a pillow to wrap around it and immobilize. Point to Emphasize Joints of the upper extremities create splinting difficulties. When possible, splint in place.

Talking Point Manage suspected fractures to the humerus by applying a rigid splint to the upper arm and securing the arm to the body using a sling and swathe. Critical Thinking Discussion Consider how a major orthopedic injury would impact a patient’s life. What steps could you take to address the emotional impact of the injury? Upper arm (humerus) Rigid splint Sling and swathe

Talking Points Rigid or circumferential splints work well with these injuries. Apply the splint leaving the fingers exposed to assess circulation, sensation, and motor function. Remember that you must immobilize the joint above and below the injury; use a sling and swathe after the application of a rigid splint to best immobilize the elbow. Knowledge Application Assign small groups a particular injury. Ask the group to report on the pathophysiology of the injury and the best way to treat it. Discuss. Lower arm (radius and ulna) Rigid splint Sling and swathe

Talking Points Immobilize fingers using a rigid splint, such as a tongue depressor, or by simply taping the injured finger to the next finger. If multiple fingers are involved, consider using a soft splint. Have the patient hold a roll of gauze and wrap the entire hand with a roller bandage. Fingers Rigid splint

Lower Extremity Injuries
Pelvis Padding Pelvic binder Pneumatic antishock garment Talking Points Pelvic injuries can cause life-threatening bleeding. Assess carefully for signs and symptoms of shock. Splint pelvic fractures by placing the patient on a long backboard and padding between the legs and on either side of the pelvis. You may also use a commercially available device called a pelvic binder. This device is specifically designed to immobilize the pelvis. Some EMS systems allow for the use of the pneumatic antishock garment (PASG) to immobilize unstable pelvic fractures. This device works as an air splint. Discussion Question Describe the dangers of a pelvic fracture. Why is this injury considered life threatening? Photo: © Edward T. Dickinson, M.D.

Upper leg (femur) Traction splint Rigid splint Long backboard Talking Points The femur is a large bone with large vessels that run the length of it. Because these large vessels have the potential to be damaged with a femur fracture, consider this injury a true emergency. Any force that is great enough to break the femur should make you suspicious of potential injury to other parts of the body. In an isolated femur fracture, use a traction splint to reduce pain and muscle spasm. Consider the use of two rigid splints applied to the affected leg. Remember that you must immobilize the joint above and below the injury; secure the patient to a long backboard to immobilize the hip and knee. Point to Emphasize Pelvic and femur fractures often are associated with severe blood loss. Always treat life threats before taking time to splint; however, remember that splinting itself can help minimize bleeding. Knowledge Application Distribute various types of splints. Have students review each device and report what specific injury would be best served by application of the device. Discuss. Back to Objectives

Talking Points A hip injury is usually an injury to the end of the femur closest to the joint of the pelvis. Fractures and dislocations are both common. Signs of a hip fracture include a rotated foot or a shortening of one leg as compared to the other. If the leg is bent, consider padding beneath the knees with pillows or blankets and immobilize to a long backboard. Discussion Question Describe the signs of a hip fracture. How could you recognize this type of injury in the field? Point to Emphasize Rotation of the foot and shortening of one leg compared to the other are common signs of a hip fracture. Hip Long backboard

Talking Points Like lower arm injuries, lower leg injuries are typically easy to splint using either a rigid splint or a circumferential splint. Remember to immobilize the ankle and knee (above and below the injury) and to leave the toes exposed to assess for circulation, sensation, and motor function. Discussion Question Describe the various techniques for splinting specific upper extremity and lower extremity injuries. Consider long bones and joints. Lower leg (tibia/fibula) Rigid splint Circumferential splint

Talking Points Splint the knee in the position found. Use a pillow or two rigid splints placed on either side of the knee. Remember that joint injuries often have circulatory, sensory, and motor function problems so assess constantly. Point to Emphasize A pillow is a useful splint when immobilizing an elbow, knee, or foot. Knee Rigid splint Pillow

Foot Talking Points The easiest way to splint a foot is to place the bottom of the foot on the center of a pillow and fold it up along the sides of the leg and secure it in place. Remember to leave the toes exposed for assessment. Knowledge Application Use a programmed patient to simulate various upper extremity and lower extremity injuries. Practice appropriate immobilization techniques. Lower Extremity Injuries Back to Objectives

Amputations Back to Topics Teaching Time 15 minutes Teaching Tips
Review the discussion of amputations from Chapter 20. Amputations are visually powerful. Use multimedia graphics to illustrate these types of injuries. Discuss real-life scenarios of reattached parts to underscore the importance of timely treatment of the amputated part. Use a manikin/manikin part to demonstrate amputation and amputated part care. Critical Thinking Discussion Consider how an amputation would impact a patient who is aware of it at the time of your arrival. How could you reassure the patient while doing your assessment? Knowledge Application Use a programmed patient and moulage to simulate an amputation. Practice treatment strategies. Use a simulated amputated part. Have teams of students practice caring for an amputated part according to local protocol. Back to Topics

Photos: © Charles Stewart M.D. and associates
Discussion Questions Define an amputation. Describe how you would control bleeding in an amputation. Why might bleeding control be only a minor problem in an amputation? Describe the treatment of an amputated part. Consider local protocol. Points to Emphasize An amputation occurs when a body part has been completely detached from the rest of the body. In the case of an amputation, control bleeding as you would any other open wound. Often an amputated part can be reattached. Consider treatment of the amputated part as an important aspect of the overall treatment plan. Typical care for an amputated part includes cleaning the amputated part by removing loose debris, wrapping the amputated part in moistened gauze, cooling the amputated part, and labeling the part with the patient’s name. Photos: © Charles Stewart M.D. and associates

Case Study: Transition
EMTs arrive and you describe the fall You summarize your primary assessment You turn over stabilization of the leg to them They straighten the leg with your assistance Leg is splinted and patient transported Case Study Discussion Has the treatment been handled properly? Would you have done anything differently?

REVIEW Define the following terms Axial skeleton Appendicular skeleton
Open injury (fracture) Closed injury (fracture) Strain Sprain Fracture Angulated fracture Crepitus Definitions Axial skeleton—The skull, rib cage, and spinal column Appendicular skeleton—The arms and legs (upper and lower extremities) Open injury (fracture)—A broken bone that has perforated the skin overlying the injury Closed injury (fracture)—A broken bone that has intact skin overlying the injury Strain—An injury that occurs when muscles and tendons are overworked or stretched and extended beyond their normal range of motion Sprain—An injury that occurs when ligaments that connect bone to bone are over extended and stretched beyond their normal range of motion Fracture—An injury that occurs when a bone is cracked or actually broken Angulated fracture—A normally straight bone that is bent due to a fracture Crepitus—The grating sound made when broken bone ends rub together CONTINUED

REVIEW Define the following terms Sling and swathe Traction splint
Dislocation Definitions Sling and swathe—An immobilization technique formed by the combination of a sling (triangle bandage) around the affected arm and triangle bandages securing the arm to the rest of the body Traction splint—A mechanical device that, when attached to an extremity, provides gentle pulling (traction) to help decrease pain and prevent muscle spasm Dislocation—An injury that occurs when a joint is disrupted; when a bone (or bones) that makes up part of a joint is forced out of place Back to Objectives

STOP, REVIEW, REMEMBER Which of the following would best describe the injury that occurs when ligaments are overextended and stretched beyond their normal range of motion? Strain Sprain Fracture Contusion Answer: b Have the students justify their answer. CONTINUED

STOP, REVIEW, REMEMBER A 16-year-old male was hit in the shoulder while playing football. He says that he feels like his arm “popped out of socket.” Which of the following injuries would best match his description? Strain Open fracture Dislocation Hematoma Answer: c Have the students justify their answer. CONTINUED

STOP, REVIEW, REMEMBER The grating sound heard when broken bone ends rub together is called crepitus. subcutaneous emphysema. crackles. subdermal grinding. Answer: a Have the students justify their answer. CONTINUED

STOP, REVIEW, REMEMBER When manually immobilizing a suspected musculoskeletal injury, you should replace protruding bone ends. apply direct pressure to the bone ends. dress the wound and apply a splint. apply a dressing only. Answer: c Have the students justify their answer.

REVIEW Discussion Describe the typical findings associated with musculoskeletal injuries. Describe the common types of force that typically cause musculoskeletal injuries. Differentiate between open and closed fractures. Discussion Answers Have the students justify their answers. Typical findings of musculoskeletal injuries are: pain; tenderness; deformity; open wounds; crepitus; swelling; discoloration; loss of sensation, circulation, and range of motion. The two common types of force that result in musculoskeletal injury are direct and indirect force. A closed fracture occurs when the skin is still intact; an open fracture occurs when the integrity of the skin is broken.

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