1. Musculosketal Trauma
Chapter 30

2. Objectives Review Musculoskeletal System Injuries to bones and joints
Critical Fractures
Basics of Splinting

3. The Muscles Voluntary – control at will
Voluntary make deliberate movement like walking, chewing, and frowning
Attached to the skeleton at one or both ends
Form the major muscle mass of the body
Tissue contracts when stimulated by a nerve impulse
Give out bodies their distinctive shapes

4. Muscles can be injured in many ways
Broken fibers from overextension
Bruises
Crushing
Cuts
Tears
Painful swelling and weakness

5. Tendons and Ligaments Glue that holds the body together
Composed of specialized connective tissue
Tendons – connect muscle to bone
Ligaments – connect bone to bone
Can be crushed, bruised, cut or torn

6. Cartilage Extension of the bone Comprised of connective tissue
Strong, smooth, flexible, compressible, slippery substance
Found at the point of articulation of two bones
Protects bones in motion from friction
Acts as shock absorber between bone surfaces
Leads to joint pain when injured

7. Joints allow for types of motion
Flexion – Bending, moves the extremity toward the body
Extension – Moves extremity away from body
Adduction – Toward midline of the body
Abduction – Movement of a body part away from the midline
Rotation – Turning along the axis of the bone or joint
Circumduction – Movement through an arc of a circle or in a circular motion from a central point

8. The Skeletal System
Upper Extremity – shoulder girdle, arm, forearm, hand
Clavicle (collar bone)
Scapula (shoulder)
Humerus (upper arm)
Radius (lower arm)
Ulna (includes olecranon, lower arm and elbow
Carpal bones (wrist)
Metacarpals (hand)
Phalanges (fingers)

9. Lower extremity Pelvis, thigh, leg, foot
Pelvis (including ilium, ischium, pubis)
Femur (thigh)
Patella (kneecap)
Tibia (lower leg)
Fibula (lower leg)
Calcaneus (heel)
Tarsals (ankle)
Metatarsals (foot)
Phalanges (toes)

10. Types of Injuries Fracture Strain Sprain Dislocation
General injury considerations

11. Fractures A break in the continuity of a bone
Caused by direct, indirect, or twisting force
Open – Associated with an open wound
Closed – Skin is not broken

12. Fractures Type can only be distinguished by x-ray
Pathologic Fracture
Type can only be distinguished by x-ray
Hairline – Small crack in bone, does not create instability
Pathologic – Result of a degenerative disease such as osteoporosis
Various complications
Hemorrhage from the bone
Instability of the extremity
Surrounding tissue damage
Infection (open fracture)
Interruption of distal blood supply
Epiphyseal Fracture

13. Strain Injury to a muscle or tendon
Often due to overextension (overstretching)
Can be caused by extreme muscle stress or fatigue associate with overuse
No edema or discoloration
Pain or weakness with use of the muscle

14. Sprain Injury to a joint capsule
Damage to or tearing of the connective tissue
Usually involves ligaments
Usually occurs in shoulder, knee, or ankle
Immediate pain and tenderness, followed by inflammation and swelling

15. Dislocation Displacement of bone from normal position in joint
Caused by joint being forced beyond normal range of motion
Obvious deformity and swelling; pain and tenderness
May occur at shoulder, elbow, wrist, hand, hip, knee, ankle, or foot

16. General Injury Considerations
Similar signs and symptoms; swelling, pain, or deformity
Usually associated with external forces (fall, vehicle collision)
May occur through degenerative disease, particularly in elderly patients
Force may cause injuries to surrounding soft tissues and other body areas

17. Mechanism of Injury
Direct force – injury occurs at the point of impact
Indirect force – force impacts on one end of a limb, causing injury some distance away from point of impact
Twisting force – One part of extremity remains stationary while the rest twists

18. Critical Fractures: Femur
Symptoms
Bone bleeds heavily – Up to 1.5 liters of blood
Tension on thigh muscles is lost so thigh diameter increases, allowing more blood to housed within thigh
Goals of Treatment
Immobilize bone ends
Reduce bleeding
Effect of traction splint
Bone ends are realigned, preventing further injury and reducing pain
Diameter of thigh is decreased, allowing less blood to accumulate

19. Critical Fractures: Pelvis
Bone itself bleeds heavily – Up to 2 liters of blood
Application of PASG/MAST will stabilize fracture and may help tamponade bleeding pelvis
Whatcom Co. Protocol page 17, recommends the pelvic sling in place of the PASG/MAST

20. Assessment based approach Bone or Joint Injuries
Scene size-up/Primary Assessment
BSI
Consider MOI
Ask bystanders what caused the injury
Imagine the forces to which the patient’s body was subjected.
Check for signs of severe hemorrhage
Look for signs of shock and treat
If injury has caused a life-threatening condition, immobilize injured extremity and transport immediately

21. Secondary Assessment
If patient has life-threatening injury, not directly related to injury, initiate transport, immobilize enroute to hospital if time and patient’s condition allows
Patient is responsive and oriented, inspect and gently palpate bone or joint
Be gentle and reassuring
Check injury site for signs/symptoms of injury (deformity, contusions, tenderness)
Check for Crepitis
Assess baseline vitals and obtain a history
Greenstick Fracture

22. Secondary Assessment Evaluate the 6 “Ps” Pain Pallor
Paralysis – May indicate nerve, muscle, tendon or ligament damage
Paresthesia – May indicate nerve damage (Numbness, prickly feeling, or tingling)
Pressure – May indicate damaged tissue or internal blood loss
Pulse – Decreased or absence of distal pulse may indicate arterial damage

24. Emergency Care
Life-threatening, immobilize injured extremity during primary/secondary assessments if appropriate and does not delay transport
If patient has other life-threatening condition, initiate transport, then immobilize enroute
Immobilize suspected fracture
BSI
Oxygen
Maintain in-line stabilization if spine injury suspected
Splint bone and joint
Apply cold packs to painful, swollen, or deformed extremity
Elevate extremity (No spine injury)
Transport
Reassess vital signs, splinting
Check distal pulses, motor function and sensation after immobilizing

25. General rules to Splinting
Before and after splinting, assess pulse, motor function, and sensation distal to the injury
Immobilize joints above and below a long bone injury
Remove or cut away clothing and jewelry around the injury site
Cover all wounds with sterile dressings and gently bandage before splinting
If there is severe deformity or the distal extremity is cyanotic or lacks pulses, align injured limb with gentle manual traction before splinting

26. General rules to Splinting continued
Never intentionally replace protruding bones or push them back below the skin
Pad each splint to prevent pressure and discomfort
Apply the splint before trying to move the patient
When in doubt, splint the injury
If patient shows signs of shock, do not apply splint first; align patient in normal anatomical position, treat for shock, transport immediately

27. Splinting equipment Rigid splints Commercially manufactured
Made of wood, wood fiber, plastic or cardboard
Designed to fit specific limbs, or can be molded to fit any appendage
May come with washable pads

28. Pressure (air/pneumatic) splints
Soft and pliable before inflation; rigid once applied and inflated
Cannot be sized
May impair circulation
May interfere with ability to assess pulses
May lose or gain pressure with changes in temperature/altitude
Seek medical direction regarding use

29. Traction Splints
Provide a counterpull that alleviates pain, reduces blood loss, and minimizes further injury
Purpose is to immobilize bone ends, reduce diameter of thigh, and prevent further injury
Many types available

30. Formable splints & Vacuum splints
Rigid but made to be shaped to fit deformed extremity
Can fixed in place with cravats or Velcro
Typically composed of wire, aluminum or other flexible metal
Vacuum Splint
Soft and pliable
Easily formed to deformed extremities
When air is sucked out, splint becomes rigid

31. Sling and swathe
Provides stability to injured shoulder, elbow or upper humerus
Sling support arm; swathe holds arm against chest
Minimizes pain and further injury

32. Spine board Considered a full body splint
Use in cases of critical injury to provide stability where extremity fractures cannot be splinted at scene

33. Improvised splints Light in weight but firm and rigid
As wide as thickest part of fractured limb
Long enough to extend past joints and prevent movement
Padded well so inner surfaces are not in contact with skin
Possible materials include cane, cardboard, umbrella, pillow, blanket

34. Hazards of Improper splinting
Compression of nerves, tissues, and blood vessels
Delay in patient’s transport
Reduction of distal circulation
Aggravation of bone or joint injury
Aggravation or cause of damage to tissue, nerves, blood vessels, or muscles

35. Splinting long bone injuries
Look for exposed bone ends, joints locked in position, paresthesia (tingling), paralysis, and pallor
Assess pulse, motor function, and sensory below the injury site
If limb severely deformed, cyanotic, or lacks distal pulses, align with gentle traction

36. Splinting joint injuries
Look for paresthesia or paralysis
Assess the pulse, motor and sensory function below the injury site
If distal extremity is cyanotic, or lacks distal pulses, align with gentle traction; stop if pain or crepitus increases

37. Traction Splinting Use for fractured femur Reduces diameter of thigh
Decreases space in which bleeding can occur
Do not use in the following instances;
Injury is within one to two inches of the knee or ankle
Knee itself is injured
Hip is injured
Pelvis is injured
There is partial amputation or avulsion with bone separation

38. Splinting Specific Injuries
Special techniques may be applied to the splinting of suspected bone and joint injuries to specific sites
Review splinting techniques for the shoulder, upper arm, elbow, forearm, wrist, hand, fingers, pelvis, hip, thigh, knee, lower leg, ankle, and foot

39. Pelvic Fracture
PASG can splint pelvis and decrease compartment size to reduce bleeding
Commercial pelvic splint is another method
Improvised pelvic wrap may be applied if necessary
Fold a sheet lengthwise to 8” width
Slide it under the small of the back, then down under the pelvis until centered. Ends of the sheet must be of equal length on both sides of patient
Cross tail ends over patient and twist until sheet is tightly secured around pelvis
Tuck sheet ends under patient or tie into square knot
Place patient on backboard or rigid device

40. Compartment Syndrome
May occur when fracture or injury to an extremity has occurred
May occur in buttock or abdomen
Occurs when pressure in space around capillaries exceed pressure needed to perfuse tissues; blood flow is cut off and cells become hypoxic
Usually develops over time as edema around injured area increases
Commonly associated with fractures, bleeding from trauma, crush injuries, and high-energy trauma

41. Compartment Syndrome Signs/Symptoms Severe pain or burning sensation
Decreased strength in extremity
Paralysis of extremity
Pain with movement
Extremity feeling hard to palpitation
Distal pulses, motor, and sensory function possibly normal
Treatment
Immobilize and splint affected extremity
Elevate extremity and apply cold pack to ice
Transport ASAP

43. Questions ????