Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Sports Injuries: “Head, shoulders, knees and toes. . .” Presence Regional EMS System August 2015 Objectives Discuss the structure and function of the musculoskeletal system Compare the orthopedic physiology for growing children, mature adults, and geriatric patients. Name 4 mechanisms of injury related to sports injuries Discuss the assessment and management of patients with sports injuries including pain management. Objectives Outline the basic principles of splinting Using a variety of scenarios describe the assessment and management of sports injuries. Functions of the Musculoskeletal System Provides the body shape Provides the internal structures with protection Provides for movement Muscles Three types: – Skeletal Gives body shape and movement – Smooth Lines internal organs – Cardiac Heart muscle Skeleton – Components Skull Spinal column Thorax Pelvis Lower extremities Upper extremities Joints Joints: – Formed wherever two bones meet Tendons: – connect muscle to bone. Ligaments: – connect bone to bone. Anatomy and Physiology Children and Adolescents – Not just small adults – Bones, muscles, tendons, and ligaments are still growing Can create a serious growth plate injury Children and Adolescents – Abdominal muscles are less developed Increases chance of internal organ injury with blunt trauma – Liver and spleen more exposed until puberty Increases chance of internal organ injury with blunt trauma Anatomy and Physiology Adults – Muscle and bones fully developed – Warm up and cool down phase important – Female athletes have a higher number of injuries May be related to training methods – Highest number of injuries associated with recreational sports (racquet sports, golf, bowling, and hiking) Anatomy and Physiology Elderly – Osteoporosis makes bones more susceptible to fractures and slows the healing process – Vertebrae of the spine narrow, causing curvature in the spine (seen in 2 out of 3 patients) – Joints loose mobility falls – Loss of muscle mass falls Elderly Athletes – Loss of balance falls – Thinning of skin More prone to injury and slower healing – Less perspiration is produced More prone to heat related injury Mechanisms of Injury Force may be applied in several ways: – Direct Force – Indirect force – Twisting force – High-energy injury High School Sports Injuries Types of Injuries Muscle sprains and strains Knee injuries Compartment syndrome Achilles tendon injuries Fractures Dislocations Head and neck injuries Types of Injuries Strain – Twisting, pulling or tearing of a muscle or tendon (connects muscle to bone) – Noncontact injury resulting from overstretching or over contracting – Range from mild to severe – Signs and symptoms include: Pain Muscle spasm Loss of strength swelling Types of Injuries Sprain – Stretching or tearing of a ligament – Caused by trauma (i.e. fall or direct hit to a joint) – Range from first degree (minimal stretching) to third degree (a complete tear). – Most common joints effected include ankles, knees, and wrists. – Signs and symptoms include: Pain/tenderness Bruising Swelling Inability to move joint Joint looseness or instability Types of Injuries Knee injuries – Most commonly injured joint – Result from a direct blow or twisting, improper landing after a jump, or running too hard, too much, or without proper warmup. – Signs and symptoms: Pain Swelling Bruising Inability to move joint/extremity Inability to bear weight Lateral View of the Knee Types of Injuries Compartment Syndrome – Muscles are enclosed in fascia, a tough membrane. – Muscles become injured, swelling can occur inside the fascia, not allowing for expansion. – Nerves, blood vessels and muscle can become compressed, causing damage. – Signs and symptoms: Severe pain or burning sensation Decreased strength in the extremity Paralysis of the extremity Pain with movement Extremity feeling hard to palpation Compartment Syndrome Early symptoms – Pain – Paresthesia Late symptoms – Pain – Pallor – Pulselessness – Paresthesia – Paralysis Types of Injuries Achilles tendon injury – Tendon connecting the calf muscle to the heel – Tearing or stretching the tendon – Most common in middle-aged “weekend warriors” (do not exercise routinely, and do not warmup) – Most occur during acceleration – Signs and symptoms: Severe sudden pain Inability to move foot Inability to bare weight Types of Injuries Fractures – Acute Fractures Open vs. closed Signs and symptoms: – Pain – Swelling – Bruising – Numbness or tingling Types of 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. Critical Fractures Fractures usually not fatal. Management of ABCs, C-spine is priority. HOWEVER: Two potentially deadly fractures: – Femur – Pelvis – Potentially life-threatening blood loss. – Look for S+S of SHOCK. Greenstick Fracture Incomplete fracture: often occurs in children Comminuted Fracture Shattering/fragmentation Pathologic Fracture Weakened or diseased bone: little force needed Ex: Osteoporosis, bone cancer Epiphyseal Fracture •Fracture of growth plate •Can affect growth/development ← Closed Fracture Open Fracture → Stress Fractures Most common in the feet and legs Most common in sports that have repetitive impact (i.e. gymnastics and track and field) Signs and symptoms: –Pain that increases with weightbearing –Tenderness –Swelling Signs and Symptoms of a Fracture Deformity Tenderness Guarding Swelling Bruising Signs and Symptoms of a Fracture Crepitus False motion Exposed fragments Pain Locked joint Open Bone and Joint Injury Types of Injuries Dislocation – A disruption in the joint, or separation of a joint – Caused by contact sports, high impact sports, and sports resulting in excessive stretching – Most common dislocated joints are in the hand, followed by the shoulder. Knees, hips, and elbows are less common. – Signs and symptoms: Pain Unable to use extremity involved Numbness, tingling in effected extremity Elbow Dislocation Elbow Dislocation Types of Injuries Head injuries – Concussion most common – Brain injury is the leading cause of sports-related death to children Brain Injuries Concussion – No structural injury to brain – Level of consciousness Variable period of unconsciousness or confusion Followed by return to normal consciousness – Retrograde short-term amnesia May repeat questions over and over – Associated symptoms Dizziness, headache, nausea and/or ringing in ears Brain Injuries Cerebral contusion – Bruising of brain tissue Swelling may be rapid and severe ** potentially fatal – Level of consciousness Prolonged unconsciousness, profound confusion or amnesia – Associated symptoms Focal neurological signs May have personality changes Neck injuries – Most common sport involved is football. Equipment Removal Most protective equipment can be removed without issues – Baseball gloves – Baseball helmets – Baseball catching equipment – Skateboarding pads/helmets – Bicycle helmets – Winter sports gear Special Spinal Motion Restriction (SMR) Situations Protective gear • Motorcycle helmet: removal if Poorly fitted to patient Significant neck flexion Full face and open face • Note: Remove to evaluate and manage airway Spinal Trauma - 45 Special SMR Situations Protective gear • Remove athletic helmet when: Face mask cannot be removed Airway cannot be controlled Does not hold head securely Helmet prevents stabilization • Note: Cut chin strap; do not unhook Spinal Trauma - 46 Equipment Removal Pearls Football helmet and shoulder pads – Remove face mask Cut the clips that secure the face mask with pruning shears or PVC pipe cutters or The coaching staff may have special tools to remove the face mask Do not use a screwdriver. This creates too much movement of the head/neck. Equipment Removal Pearls – Do not remove helmet completely unless Airway compromise Full cardiac arrest **If helmet needs removed, must remove shoulder pads as well** Immobilization with Football Equipment Maintain inline stabilization by holding the sides of the helmet Remove the face mask Leave helmet, chin strap, and shoulder pads in place if possible. A six person lift is recommended to move the patient to a spine board Secure to board with straps Pad sides of helmet with towel or blanket rolls Tape helmet to board Special SMR Situations Protective gear • Shoulder pad: removal if Helmet removed Unable to maintain neutral alignment Unable to secure to board Access to chest needed • Note: Cut axillary straps and laces on front, open from core outward, slide out from under Spinal Trauma - 50 Assessing Sports Injuries Follow BSI precautions Scene Size-up: – Assess mechanism of injury Initial assessment: – – – – – General impression C-Spine control if needed AVPU ABC’s Priority – Any problems – High Priority! – Give O2 to keep oxygen saturation > 94% Assessment Physical exam – Unstable patient (High Priority) -- Rapid trauma assessment (DCAPP-BTLS) – Stable patient -- exam focused on area of complaint Isolated Sports Injury If focused exam for extremity injury assess for: – Pain – Deformity – Tenderness on palpation – Crepitus – Loss of function – Open wounds – Discoloration – Exposed bone – Abnormal rotation of extremity Assessing Sports Injuries If patient critically injured, transport immediately Be alert for compartment syndrome Splint injury Transport Check neurovascular status during transport Evaluating Neurovascular Function Examination of the injured limb should include assessment of the following: – Pulse – Capillary refill – Sensation – Motor function Emergency Medical Care Completely cover open wounds. Apply the appropriate splint. If swelling is present, apply ice or cold packs. Prepare the patient for transport. Always inform hospital personnel about wounds that have been dressed and splinted. Pain Control for Athletic Injuries Advanced Providers only Adults: – MORPHINE SULFATE 5 mg slow IVP or 10 mg IM. May repeat IVP dose x 1 after 15 minutes if needed. – FENTANYL IV – 1 mcg/kg slow IVP; may repeat x 1 after 5 minutes if needed. IM – 2 mcg/kg (maximum dose 100 mcg). IN – 1 mcg/kg (1 ml per nostril via atomizer*); maximum first dose 50 mcg; May repeat x 1 after 5 minutes at 0.5 mcg/kg (maximum second dose 25 mcg) if needed. Pediatrics -- Consider MORPHINE SULFATE or FENTANYL as needed for pain control: – MORPHINE SULFATE 0.1 mg/kg slow IVP (max. single dose 5 mg) May repeat IVP dose x 1 after 15 minutes if needed 0.2 mg/kg IM (max. dose 10 mg). – FENTANYL – IV – 1 mcg/kg slow IVP; may repeat x 1 after 5 minutes if needed. – IM – 2 mcg/kg (maximum dose 100 mcg). – IN – 1 mcg/kg (1 ml per nostril via atomizer*); maximum first dose 50 mcg; May repeat x 1 after 5 minutes at 0.5 mcg/kg (maximum second dose 25 mcg) if needed. Splinting Flexible or rigid device used to protect extremity Injuries should be splinted prior to moving patient, unless the patient is critical. Splinting helps prevent further injury. Improvise splinting materials when needed. General Principles of Splinting Expose the injury: Remove clothing from the area. Note and record the patient’s neurovascular status. (PMS) Cover all wounds with a dry, sterile dressing. Do not move the patient before splinting. General Principles of Splinting Immobilize the joints 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 in position found. General Principles of Splinting Immobilize all suspected spinal injuries in a neutral in-line position. If the patient has signs of shock, align limb in normal anatomic position and transport. When in doubt, splint. MANAGEMENT LOAD & GO PATIENTS Spinal immobilization –Long backboard –C-collar –Head immobilizer Limit splinting until en route Backboard acts as “whole body” splint 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 Assessment Pearl Check distal pulse, movement and sensation (PMS) prior to moving/splinting the patient, AND after. This includes spinal immobilization. Specific Musculoskeletal Injuries Clavicle Fracture Clavicle and Scapula Injuries Clavicle is one of the most fractured bones in the body. Scapula is wellprotected. Joint between clavicle and scapula is the acromioclavicular (A/C) joint. Splint with a sling and swathe. Shoulder Dislocation Dislocation/Fx of the Shoulder Most commonly dislocated large joint Usually dislocates anteriorly Is difficult to immobilize What Is Wrong With This Splint?? What Is Wrong With This Splint? The patient’s Hand and wrist are Not supported. Swath is too narrow. Fractures of the Humerus Occurs either proximally, in the midshaft, or distally at the elbow. Consider applying traction to realign a severely angulated humerus, according to local protocols. Splint with sling and swathe, supplemented with a padded board splint. ELBOW INJURY Fracture or dislocation may cause neurovascular injury Splint in position found Transport promptly If long transport time, contact Medical Control Extremity Trauma Elbow: one attempt to reposition if no pulse Extremity Trauma - 78 Fractures of the Forearm Usually involves both radius and ulna Use a padded board, air, vacuum, or pillow splint. Hand in position of function– slightly curled around bandage Forearm Fracture Injuries to the Wrist and Hand Follow BSI precautions. Cover all wounds. Apply padded board splint. Secure entire length of splint. Apply a sling and swathe. Place hand in position of function Position of Function Hand Injuries Fractures of the Pelvis May involve life-threatening internal bleeding Assess pelvis for tenderness. Stable patients can be secured to a long backboard or scoop stretcher to immobilize isolated fractures of the pelvis. Consider ways to stabilize fractured pelvis. Splinting a Pelvis Fracture Courtesy of Sam Splints Extremity Trauma - 85 HIP FRACTURE Common in the elderly May be able to support weight – Ability to walk does not rule out fracture Leg often externally rotated May refer pain to the knee Use other leg for splint Use vacuum backboard if available Hip Fracture Splinting Hip Fracture Extremity Trauma - 88 HIP DISLOCATION Orthopedic emergency Posterior dislocation most common Hip flexed, leg shortened and rotated internally Severe pain on attempts to straighten COURTESY ROY ALSON, M.D. MANAGEMENT HIP DISLOCATION Splint in most comfortable position Document distal PMS Prompt transport Be alert for associated knee injuries Femur Fractures Muscle spasms can cause deformity of the limb Significant amount of blood loss will occur. Immobilize with traction splint. Femur Fracture Traction Splints • Three kinds: • Sager • Hare • Kendrick • Use for the following: • Femur Fracture only • Midshaft • Closed injury 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 Traction Splints Hare Traction Splint Sager Traction Splint KNEE FRACTURE OR DISLOCATION Orthopedic emergency Frequently causes vascular injury Dislocation associated with high incidence of leg amputation MANAGEMENT KNEE DISLOCATION Obvious dislocation without distal pulse – Apply gentle in-line traction – only once If gentle traction does not restore the pulse – Splint in place Prompt transport Dislocation of the Patella Usually dislocates to lateral side. Produces significant deformity. Splint in position found. Support with pillows. Extremity Trauma Knee : may reposition once to get pulse Extremity Trauma - 98 Injuries to the Tibia and Fibula Usually, both bones fracture at the same time. Open fracture of tibia common. Immobilize with a padded rigid long leg splint or an air splint that extends from the foot to upper thigh. Splinting the Lower Leg Extremity Trauma - 10 0 Ankle Injuries Most commonly injured joint Dress all open wounds. Assess distal neurovascular function. Correct any gross deformity by applying gentle longitudinal traction to the heel. Before releasing traction, apply a splint. Foot Injuries Usually occur after a patient falls or jumps. Immobilize ankle joint and foot. Leave toes exposed to assess neurovascular function. Elevate foot 6”. Also consider possibility of spinal injury from a fall. Skills Practice Put slips of paper with the following injuries in a hat. Have individuals pull out an injury and practice placing appropriate splints on each other for those injuries. Skills Practice Injuries Clavicle Upper arm Lower arm Pelvis Femur Lower leg Foot Shoulder Elbow Hand Hip Knee Ankle Review Answer the following questions as a group. If doing this CE individually, please e-mail your answers to: [email protected] Use “August 2015 CE” in subject box. You will receive an e-mail confirmation. Print this confirmation for your records, and document the CE in your PREMSS CE record book. IDPH site code: 06-7100-E-1215 1. Give three assessments that are performed during splinting. 2. A 17-year-old young man was pole vaulting. He lost his balance and fell 17+ feet onto the ground. His left leg is swollen and deformed at the mid-shaft femur area. What is your initial management of this injury? 3. 4. 5. In addition to the injury in question 2, what other concerning complication do you expect with this patient? A 15 year-old girl has sustained a painful, swollen and deformed right shoulder while playing basketball. She has a good right radial pulse. How should this injury be managed? Should the arm/shoulder be realigned? Why or why not? 6. Name four common sports related injuries. 7. Name the two times a football helmet is removed. Answers 1. Assess distal pulses, movement and sensation 2. Following assessment of Airway, Breathing, Circulation then apply a traction splint. 3. This patient is at risk of hemorrhagic shock. 4. Splint in place using padding and a sling/swath. 5. Do not attempt to realign the deformed shoulder because the girl has a radial pulse. Splint in place. 6. Muscle sprains and strains Knee injuries Compartment syndrome Achilles Tendon injuries Fractures, dislocations Head and neck injuries 7. Remove the helmet in the case of airway compromise or cardiac arrest.