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Chapter 24 Principles of Musculoskeletal Injuries Chapter 24: Principles of Musculoskeletal Injuries Objectives (1 of 3) • Describe the function of the muscular system. • Describe the function of the skeletal system. • List the major bones or bone groupings of the spinal column, the thorax, the upper extremities,and the lower extremities. • Differentiate between an open and closed painful, swollen, deformed extremity (fracture). 2 Chapter 24: Principles of Musculoskeletal Injuries Objectives (2 of 3) • State the reasons for splinting. • List the general rules for splinting. • List the complications of splinting. • Explain the rationale for splinting at the scene versus load and go. 3 Chapter 24: Principles of Musculoskeletal Injuries Objectives (3 of 3) • Demonstrate the emergency care principles for injured extremities. • Demonstrate the basic principles of applying the three basic splint types: rigid fixation, soft fixation, and traction splints. 4 Chapter 24: Principles of Musculoskeletal Injuries Anatomy and Physiology of the Musculoskeletal System 5 Chapter 24: Principles of Musculoskeletal Injuries Types of Muscle • Skeletal muscles – Attach to bone by tendons – Voluntary • Smooth muscles – Involuntary • Cardiac muscle – Specialized and has separate regulatory systems 6 Chapter 24: Principles of Musculoskeletal Injuries Skeletal System 7 Chapter 24: Principles of Musculoskeletal Injuries Joints • A joint is formed wherever two bones come into contact. • Ligaments hold bones together. • Articular cartilage allows bone ends to glide easily. • Joints are lubricated by synovial fluid. 8 Chapter 24: Principles of Musculoskeletal Injuries Types of Musculoskeletal Injuries • Fracture – Broken bone • Dislocation – Disruption of a joint • Sprain – Joint injury with tearing of ligaments • Strain – Stretching or tearing of a muscle 9 Chapter 24: Principles of Musculoskeletal Injuries Mechanism of Injury • Force may be applied in several ways: – Direct blow – Indirect force – Twisting force – High-energy injury 10 Chapter 24: Principles of Musculoskeletal Injuries Fractures • Closed fracture – A fracture that does not break the skin • Open fracture – External wound associated with fracture • Nondisplaced fracture – Simple crack of the bone • Displaced fracture – Fracture in which there is actual deformity. 11 Chapter 24: Principles of Musculoskeletal Injuries Greenstick Fracture 12 Chapter 24: Principles of Musculoskeletal Injuries Comminuted Fracture 13 Chapter 24: Principles of Musculoskeletal Injuries Pathologic Fracture 14 Chapter 24: Principles of Musculoskeletal Injuries Epiphyseal Fracture 15 Chapter 24: Principles of Musculoskeletal Injuries Signs and Symptoms of a Fracture (1 of 2) • Deformity • Tenderness • Guarding • Swelling • Bruising 16 Chapter 24: Principles of Musculoskeletal Injuries Signs and Symptoms of a Fracture (2 of 2) • Crepitus • False motion • Exposed fragments • Pain • Locked joint 17 Chapter 24: Principles of Musculoskeletal Injuries Signs and Symptoms of a Dislocation • • • • • • Marked deformity Swelling Pain Tenderness on palpation Virtually complete loss of joint function Numbness or impaired circulation to the limb and digit 18 Chapter 24: Principles of Musculoskeletal Injuries Signs and Symptoms of a Sprain • Point tenderness can be elicited over injured ligaments. • Swelling and ecchymosis appear at the point of injury to the ligaments. • Instability of the joint is indicated by increased motion. • Pain 19 Chapter 24: Principles of Musculoskeletal Injuries Assessing Musculoskeletal Injuries (1 of 2) • • • • • • Assess mechanism of injury. Perform initial assessment. Perform focused physical exam. Follow BSI precautions. Give oxygen if needed. Follow DCAP-BTLS. 20 Chapter 24: Principles of Musculoskeletal Injuries Assessing Musculoskeletal Injuries (2 of 2) • If patient critically injured, arrange for immediate transport. • Be alert for compartment syndrome. • Splint injury. • Transport. • Monitor neurovascular status during transport. 21 Chapter 24: Principles of Musculoskeletal Injuries Evaluating Neurovascular Function • Examination of the injured limb should include assessment of the following: – Pulse – Capillary refill – Sensation – Motor function 22 Chapter 24: Principles of Musculoskeletal Injuries Severity of Injury • Critical injuries can be identified using musculoskeletal injury grading system. • Refer to Table 24-1 on page 587. 23 Chapter 24: Principles of Musculoskeletal Injuries Emergency Medical Care • Completely cover open wounds. • Apply appropriate splint. • If swelling is present, apply ice or cold packs. • Prepare patient for transport. • Always inform EMS about wounds that have been dressed and splinted. 24 Chapter 24: Principles of Musculoskeletal Injuries Splinting • Use a flexible or rigid device to protect extremity. • Injuries should be splinted prior to moving the patient, unless patient is critical. • Splinting helps prevent further injury. • Improvise splinting materials when needed. 25 Chapter 24: Principles of Musculoskeletal Injuries General Principles of Splinting (1 of 3) • Remove clothing from the area. • Note and record patient’s neurovascular status. • Cover all wounds with a dry, sterile dressing. • Do not move patient before splinting. 26 Chapter 24: Principles of Musculoskeletal Injuries General Principles of Splinting (2 of 3) • Immobilize the bones above and below the injured joint. • Pad all rigid splints. • Maintain manual immobilization. • Use constant, gentle, manual traction if needed. • If you find resistance to limb alignment, splint the limb as is. 27 Chapter 24: Principles of Musculoskeletal Injuries General Principles of Splinting (3 of 3) • Immobilize all suspected spinal injuries in a neutral in-line position. • If the patient has signs of shock, align limb in normal anatomic position on a backboard and transport. • When in doubt, splint. 28 Chapter 24: Principles of Musculoskeletal Injuries Rigid Fixation Splints • Firm material applied to fractures that prevent motion – Quick splints – Cardboard – Wire and ladder splints – SAM® splint 29 Chapter 24: Principles of Musculoskeletal Injuries Soft Fixation Splints • • • • Air splints Vacuum splints Sling and swathe Blanket/pillow splints 30 Chapter 24: Principles of Musculoskeletal Injuries Applying a Quick Splint (1 of 2) • Open the quick splint. • Assess distal CMS functions of the leg. • Manually stabilize leg by grasping foot and leg behind and below the knee. • Slight longitudinal traction can be used. • Elevate the extremity carefully. • The “pant-leg pinch lift” can also be used. 31 Chapter 24: Principles of Musculoskeletal Injuries Applying a Quick Splint (2 of 2) • Have second rescuer slide the open splint under the leg. • Lower leg carefully into splint. • Second rescuer can fold sides of splint and secure straps, cords, etc. • Reassess distal CMS functions of the leg. 32 Chapter 24: Principles of Musculoskeletal Injuries Applying a Sling and Swathe (1 of 2) • Assess distal CMS functions. • Carefully bend injured arm to just < 90° and lay a cravat on the chest under the arm, with a 90° point at the elbow. • Bring lower end up and over shoulder on injured side. • Bring upper end over opposite, uninjured shoulder and tie at side of neck. 33 Chapter 24: Principles of Musculoskeletal Injuries Applying a Sling and Swathe (2 of 2) • Secure a second cravat, 3” to 6” wide, around the chest and injured upper arm. • To avoid pressure on the injured shoulder, alternately, bring lower end through injured arm’s armpit and tie it over the scapula. • Reassess distal CMS functions. 34 Chapter 24: Principles of Musculoskeletal Injuries Applying a Blanket Roll (1 of 2) • Fold blanket longitudinally into thirds. • Lay two or three cravats near end of blanket and roll firmly. • Assess distal CMS functions. 35 Chapter 24: Principles of Musculoskeletal Injuries Applying a Blanket Roll (2 of 2) • Position roll snugly under injured shoulder; tie one cravat over uninjured shoulder. Secure other(s) around chest and/or waist. • Secure injured arm with sling and swathe. • Reassess distal CMS. 36 Chapter 24: Principles of Musculoskeletal Injuries Applying a Vacuum Splint • • • • Stabilize and support injury. Place splint and wrap it around limb. Draw air out of splint and seal valve. Check and record distal CMS functions. 37 Chapter 24: Principles of Musculoskeletal Injuries Improvised Splints • Use rigid or semi-rigid materials. Examples: – Skis, ski poles – Boards, branches – Blankets, pillows, camping pads – Shovels, probes, ice axes – Uninjured part, ie, finger, leg, chest wall 38 Chapter 24: Principles of Musculoskeletal Injuries In-line Traction Splinting • Act of exterting a pulling force on a bony structure in the direction of its normal alignment. • Realigns fracture of shaft of a long bone. Usually used for femur fractures. • Use the least amount of force necessary. • If resistance is met or pain increases, splint in deformed position. 39 Chapter 24: Principles of Musculoskeletal Injuries Traction Splints • Do not use a traction splint under the following conditions: – Upper extremity injuries – Injuries close to or involving the knee – Pelvis and hip injuries – Partial amputation or avulsions with bone separation – Lower leg or ankle injuries 40 Chapter 24: Principles of Musculoskeletal Injuries Applying a Traction Splint (1 of 3) • An angulated fracture will need to be realigned before a splint can be applied. • Manually stabilize fracture site. • Expose site and care for any open wounds. • Per local protocol, remove footwear and assess distal CMS functions. 41 Chapter 24: Principles of Musculoskeletal Injuries Applying a Traction Splint (2 of 3) • Prepare splint for application. • Smoothly realign fracture and maintain traction. • Fasten ankle hitch. • Support fracture and transfer traction to ankle hitch. • Position splint; pad and secure ischial strap. 42 Chapter 24: Principles of Musculoskeletal Injuries Applying a Traction Splint (3 of 3) • Carefully transfer traction to splint. • Secure splint to leg. • Reassess distal CMS functions. • Logroll patient onto backboard and secure. 43 Chapter 24: Principles of Musculoskeletal Injuries Applying a Sager Traction Splint (1 of 2) • Manually stabilize fracture. • Assess distal CMS functions. • Expose site and care for any open wounds. • Adjust thigh strap. • Estimate proper splint length. • Arrange ankle pads to fit. • Place splint along inner aspect of thigh. 44 Chapter 24: Principles of Musculoskeletal Injuries Applying a Sager Traction Splint (2 of 2) • • • • • • Secure ankle harness. Snug cable ring against bottom of foot. Pull out inner shaft of splint to apply traction. Secure splint to leg. Secure patient to backboard. Reassess CMS function. 45 Chapter 24: Principles of Musculoskeletal Injuries Hazards of Improper Splinting • Compression of nerves, tissues, and blood vessels • Delay in transport of a patient with a life-threatening condition • Reduction of distal circulation • Aggravation of the injury • Injury to tissue, nerves, blood vessels, or muscle 46 Chapter 24: Principles of Musculoskeletal Injuries Improvised Traction Splints • Single-ski technique – Pre-made pockets – Cravats • Two ski poles • Two paddles • Scoop stretcher 47 Chapter 24: Principles of Musculoskeletal Injuries Ski Boot Removal (1 of 2) • Guided by local protocol. • Many factors can influence protocol. – Transport time – Injury – Type of splint used – CMS status • Boot should be removed before patient arrives at hospital. 48 Chapter 24: Principles of Musculoskeletal Injuries Ski Boot Removal (2 of 2) • • • • Stabilize lower leg. Loosen all buckles, straps, and laces. Spread boot shell and pull out boot tongue. Apply tension to back of boot and pressure to boot toe with shoulder. • Rotate the boot off the foot. • Monitor for pain. Modify as needed. • Assess distal CMS functions and splint. 49