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Musculoskeletal
Provincial Reciprocity Attainment Program
Skeletal System
The Skeletal System
 Consists of:
 Bones
 Cartilage
 Ligaments
 Connect Bone to Bone
 Tendons
 Connect Muscle to Bone
 Accounts for 20% of body
weight
 They are living tissue
Functions
 Support
 Supports organs and against gravity
 Protection
 Protects soft organs underneath
 Movement
 Muscles attached provide movement
 Storage
 Inner matrix has Ca salts, Fat in Yellow Bone
Marrow
 Blood Cell Formation
 Hematopoesis in the Red Bone Marrow
Structure
 Types:
 Compact
 Spongy
 Classifications
 Long
 Femur, Ulna, Radius, Tibia, Fibula
 Short
 Tarsals and Carpals
 Flat
 Cranial bones
 Irregular
 Vertebrae
General Features of the Long
Bone
Epiphyseal
Plate
Medullary
Cavity
Diaphysis
Periosteum
Epiphysis
Endosteum
Each bone has surface markings that make it unique
Divisions
 Contains 206 named bones
 Two divisions
 Axial Skeleton
 Appendicular Skeleton
Divisions
 Axial Skeleton
 80 bones form the vertical axis
 Include:
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Cranium
Vertebrae
Sternum
Ribs
Axial Skeleton
 Skull
 28 separate bones
 Hyoid bone
Axial Skeleton
 Vertebral column
 Consists of approximately 33 bones
divided into 5 regions
 7 cervical vertebrae
 C1 (Atlas) – Yes
 C2 (Axis) - No
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12 thoracic vertebrae
5 lumbar vertebrae
1 sacral bone (5 fused vertebrae)
1 coccygeal bone (3-5 fused vertebrae)
Thoracic Cage
 Protects vital organs in the thorax
 Prevents collapse of the thorax during
respiration
 12 pairs of ribs
 Sternum
 Manubrium
 Body
 Xiphoid process
Appendicular Skeleton
 126 Bones
 Consists of the bones of the upper and
lower extremities and their girdles
 Pectoral girdle
 Comprised of the scapula and clavicle
 Attaches upper limbs to the axial skeleton
Upper Extremity
 Humerus
 Second largest
bone in the body
 Radius and Ulna
 Wrist
Pelvic Girdle
 Attaches legs to trunk
 Consists of two hip bones (coxae)
 Acetabulum
Legs
 Femur
 Longest bone in the body
 Head articulates with the acetabulum
 Articulates distally with patella
 Tibia
 Larger than fibula and supports most
of leg's weight
 Distal end forms lateral malleolus,
forming medial side of ankle joint
 Fibula
 Does not articulate with femur
 Does articulate with tibia
 Distal end forms lateral malleolus,
forming lateral aspect of ankle joint
Foot
 Consists of tarsals, metatarsals,
and phalanges
 Talus articulates with tibia and
fibula
 Calcaneus
Biomechanics of Movement
 Every bone (except the hyoid bone)
connects to at least one other bone
 Three major classifications of joints
 Fibrous joints
 Cartilaginous joints
 Synovial joints
Fibrous Joints
 Consist of two bones--united by fibrous
tissue—that have little or no movement
 Sutures (seams between flat bones)
Cartilaginous Joints
 Unite two bones by means of hyaline
cartilage (synchondroses) or
fibrocartilage (symphyses)
 Synchondroses
 Slight motion (between ribs and sternum)
 Symphysis
 Slight motion, flexible (symphysis pubis)
Synovial Joints
 Contain synovial
fluid
 Allow movement
between
articulating bones
 Account for most
joints of
appendicular
skeleton
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Plane or gliding joints
Saddle joints
Hinge joints
Pivot joints
Ball-and-socket joints
Ellipsoid joints
Muscular System
Characteristics
 Excitability
 The ability to receive and respond to
stimulus
 Contractility
 The ability to contract
 Extensibility
 The ability to stretch (opposing pairs)
 Elasticity
 The ability to recoil to original shape
Functions
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Movement
Posture
Joint stability
Heat Production
Types
 Smooth
 Involuntary
 Found in the walls of organs
 Ex: Intestinal tract
 Skeletal
 Voluntary
 Cardiac
 Found only in cardiac muscle
Structure
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As a whole each muscle may be made
up of hundreds of muscle fibers
Fascia surrounds and separates each
muscle
Each muscle is surrounded by a
protective sheath called epimysium
which divides the muscle into
compartments
Each compartment contains a bundle of
fibers called a fasciculus surrounded by
a layer of tissue called perimysium
Each fiber in the fasciculus is
surrounded by a layer of tissue called
the endomysium
The coverings also contain blood
vessels and nerves
Structure
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Muscle Fibers
Each fiber is a cylindrical cell
The cell membrane is called the sacrolemma
The cytoplasm is the sarcoplasm
A special Endoplasmic Reticulum in the sarcoplasm
is called the sarcoplasmic reticulum
The sarcolemma has multiple nuclei and
mitochondria (for energy production)
Inward extensions of the sacrolemma are called Ttubules
Structure
Muscle Fibers
SACROMERE
Nerve & Blood Supply
 Have an abundant supply
 Before a muscle can contract it needs
a stimulus
 This requires ATP
 Blood supply deliver O2 and nutrients
to produce this and remove the waste
products
 One Artery and One Vein accompany
each nerve
Contraction
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Stimulated by specialized nerve
cells called motor neurons
The motor neuron and muscle(s) is
called a motor unit
Where the axon of the neuron
meets the muscle is called the
neuromuscular junction
Between the two is a small
depression in the muscle
membrane called the synaptic cleft
Contraction
 ACh is contained within the synaptic
vesicles of the axon
 Receptors for ACh are in the sacrolemma
 The combination results in a stimulus for
contraction (an impulse) which travels along
the sacrolemma into the T-tubules where a
physiological change occurs causing a
contraction
 The enzyme acetylcholinesterase
deactivates the ACh at the synaptic cleft
Sacromere Contraction
 In a relaxed muscle fiber myosin receptor sites
on the actin are inactive
 Heads on the myosin are also inactive and are
bound to ATP
 Ca is stored in the sarcoplasmic reticulum and
has a low concentration in the sarcoplasm
 An impulse into the T-tubule cause release of
Ca from the SR into the sarcoplasm
 This rapid influx changes configuration of
troponin on the actin fibers which exposes
receptor sites
Sacromere Contraction
 Simultaneously ATP is broken down to ADP
which gives energy to the myosin
 This energy allows it to interact with the actin
 The myosin heads bind forming cross-bridges
and rotate pulling the actin towards the center
of the myosin (Power stroke)
 This pulls the Z line closer together shortening
the sacromere
 This does not shorten the myofilament
 New ATP on myosin reverse the reaction
 This is the “Sliding Filament Theory”
Sacromere Contraction
 When the stimulation ceases, Ca is actively
transported into the SR
 This causes the receptor sites to close and
ceasing the contraction
 Follows the All-or-none Principle, which is
basically:
 A sufficient stimulus is need to cause a contraction
(threshold stimulus)
 A greater stimulus will not produce greater
contraction
 Not enough will elicit no response (sub-threshold
stimulus)
Whole Muscle Contraction
 Does not follow All-or-none
 Varies due to work load
 Increase contraction is achieved by motor unit
summation and wave summation
 A single stimulus causes a twitch (lab setting)
 3 stages of contraction
 lag phase
 contraction
 relaxation
Whole Muscle Contraction
 A stimulus given during relaxation phase will cause
stronger contraction, and continues to build to form a
smooth contraction called tetany (multiple wave
summation)
 Treppe (staircase) shows an increase in force with a
stimulus of same intensity
 Muscle tone is the continued state of partial
contractions of the muscles (needed for posture and
temp)
 If movement occurs it is an isotonic contraction
 If there is no movement then it is isometric
Energy Sources
 Initial Source
 ATP for the cross-bridge and active transport
 Last only 6 seconds
 Second Source
 Creatine Phospate is used to instantaneously
give its energy to ADP to synthesis ATP
 If ATP is in excess it will convert to Creatine
phosphate to store for later use
 Lasts only 10 seconds
Energy Sources
 Third Stage
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Muscles use fatty acids and glucose for energy
Fatty acids found in blood
Glucose is a derivative of the glycogen found in the muscle
If oxygen available then the fats and glucose are broken
down with aerobic metabolism (20 times more
production)
Fatty Acids or glucose + O2 → CO2 + H20 + ATP
 If oxygen is not available then glucose is the primary
source of energy (anaerobic metabolism – happens at a
faster rate)
Glucose → lactic acid + ATP
Energy Sources
 Oxygen storage
 Red fibers have myoglobin which has iron to bind with O2
 White Fibers do not contain myoglobin
 Lactic Acid
 Excessive lactic acid is send to the liver when O2 is available and
converted and stored as glycogen
 Oxygen Debt
 After strenuous exercise using anaerobic metabolism, ATP and creatine
phosphate have to be replaced, this requires O2
 Is the additional O2 needed to do this after exercise
Musculoskeletal Injury
Injury to Muscle
 Can occur due to:
 Overexertion where fibers are broken
 With trauma muscles can be bruised,
crushed, cut, or even torn even without a
break in the skin.
 Injured muscles tend to be:
 Swollen, tender and painful, weak
Classification of MS Injuries
 Injuries that result from traumatic
forces include:
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Fractures
Sprains
Strains
Dislocations
Complications
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Hemorrhage
Instability
Loss of tissue
Simple laceration and contamination
Interruption of blood supply
Nerve damage
Long-term disability
Sprains, Strains and
Dislocations
 Ligaments
 BONE to BONE
 Tendons
 MUSCLE to BONE
 Sprain is an injury to a ligament
 Strains are injuries to tendons or muscles
 Dislocations are bones of a joint that are separated
from normal position of use
Sprains
 A partial tearing of a ligament caused by a sudden
twisting or stretching of a joint beyond its normal
range of motion
 Ankle and knees are most common
 Sprains are graded by severity:
 First degree
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Ligaments are stretched but not torn
Can put weight on the ankle
 Second degree
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Ligament is partially torn, pain and swelling are greater
Painful with weight
 Third degree
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Cannot handle weight
Strains
 An injury to the muscle or its tendon
from overexertion or overextension
 Commonly occur in the back and arms
(welcome to EMS)
 May be accompanied by significant
loss of function
 Severe strains may cause an avulsion
of the bone from the attachment site
Dislocations
 Occur when the normal articulating ends of
two or more bones are displaced
 Luxation (a complete dislocation)
 Subluxation (Incomplete dislocation)
 Suspect a joint dislocation if deformity or
does not move with normal range of function
 All dislocations can result in damage and
instability
Treatment
 Due to limited diagnostic
equipment, field diagnosis is not
necessary
 They are all treated as fractures
until proven otherwise
Treatment
 Most BONE,
JOINT, and
MUSCLE injuries
will benefit from
RICE:
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Rest
Ice
Compression
Elevation
Common MOI’s
 Direct Force
 Indirect Force
 Twisting Forces
 Muscle Contractions
 Pathological
Fractures
 Any break in the continuity of the bone
 Open Fracture
 An open wound leading to the break
 The bone may or may not be exposed
 Closed Fracture
 No wound in the are of the break
 Simple
 Single fracture of the bone
 Complex
 Multiple fractures of the bone
Signs and Symptoms
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Swelling
Discoloration
Deformity
Pain
 On palpation or movement
 Crepitus
 Loss of function
 Decreased ROM
 False movement
 Decreased of absent sensory perception or
circulation distal to the injury
Types of Fractures
Epiphyseal Fracture
(Growth plate)
Assessment
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Scene Assessment
Primary survey
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Identify
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Rule out life threatening injuries and treat first
remember distracting injuries
Six P’s of MS assessment
Stabilize
Expose
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Compare to uninjured extremity
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Assess CMS
Splint
Reassess CMS
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Pain management (Call for ALS if required)
Six P’s of MS Assessment
 Pain
 Pain on palpation
 Pain on movement
 Pallor
 Pale skin or poor capillary refill
 Paresthesia
 Pins and needles sensation
 Pulses
 Diminished or absent
 Paralysis
 Pressure
Splinting
 The goal of splinting is Immobilization
of injured body part
 Helps alleviate pain
 Decreases tissue injury, bleeding and
contamination of an open wound
 Simplifies and facilitates transport
Splinting
 Splint joints above and below the fracture
 Cover open wounds to reduce
contamination
 Check CMS before and after
 Immobilize joints in position found (ensure
good vascular supply)
 Cold applied to reduce swelling and pain
(heat is used later for healing)
Rigid Splints
 Cannot be changed in shape
 Require the body part to be positioned
to fit
 Board splints
 Cardboard splints
 Can be padded to accommodate
anatomical shape and comfort
Soft or Formable Splints
 Can be molded into various shapes to
accommodate injured part
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Pillows
Blankets
Slings and swathes
Vacuum splints
Wire ladder spliints
Flexible aluminum splints (SAM splints)
Inflatable splints
Traction Splints
 Specifically designed for Mid-Shaft
femur fractures
 Provide enough traction to stabilize
and align a fracture
Upper-Extremity Injuries
Shoulder Injury
Common in the older adult because of
weaker bone structure
Frequently results from a fall on an
outstretched arm
Shoulder Injury
 Anterior fracture or dislocation
Patient often positioned with the affected arm or
shoulder close to the chest
Lateral aspect of the shoulder appears flat
instead of rounded
Deep depression between the head of the
humerus and the acromion laterally (“hollow
shoulder”)
 Posterior fracture or dislocation
Patient may be positioned with the arm above the
head
Shoulder Injury – Management
 Assessment of
neurovascular
status
 Application of a
sling and swathe
 Application of a
cold pack
 Splinting may
need to be
improvised to hold
the injury in place
Humerus Injury
Common in older adults and children
Often difficult to stabilize
Associated complications
Radial nerve damage may be present if a
fracture occurs in the middle or distal
portion of the humeral shaft
Fracture of the humeral neck may cause
axillary nerve damage
Internal hemorrhage into the joint
Humerus Injury –
Management
 Assessment of
neurovascular status
 Traction if there is
vascular compromise
 Application of a rigid
splint and sling and
swathe or splinting the
extremity with the arm
extended
 Application of a cold
pack
Elbow Injury
 Common in children and athletes
 Especially dangerous in children
 May lead to ischemic contracture with
serious deformity of the forearm and a clawlike hand
 Usually involves falling on an outstretched
arm or flexed elbow
 Associated complications
Laceration of the brachial artery
Radial nerve damage
Elbow Injury – Management
 Assessment of
neurovascular status
 Splinting in the
position found with a
pillow, rigid splint, or
sling and swathe
 Application of a cold
pack
Radius, Ulnar, or Wrist Injury
Usually result from a fall on an
outstretched arm
Wrist injuries may involve the distal
radius, ulnar, or any of the eight carpal
bones
Common injury is Colles' fracture
Forearm injuries are common in both
children and adults
Radius, Ulnar, or Wrist Injury –
Management
 Assessment of
neurovascular status
 Splinting in the position
found with rigid or
formable splints or sling
and swathe
 Application of a cold
pack and elevation
Hand (Metacarpal) Injury
Frequently results from:
Contact sports
Violence (fighting)
Crushing in industrial context
A common injury is boxer's fracture
Results from direct trauma to a closed fist
fracturing the fifth metacarpal bone
Injuries may be associated with
hematomas and open wounds
Hand Injury – Management
Assessment of neurovascular status
Splinting with rigid or formable splint in
position of function
Application of a cold pack and elevation
Finger (Phalangeal) Injury
 May be immobilized with foam-filled aluminum
splints or tongue depressors or by taping injured
finger to adjacent one (“buddy splinting”)
 Finger injuries are common
 Should not be considered trivial
 Serious injuries include:
 Thumb metacarpal fractures
 Any open fracture
 Markedly comminuted metacarpal or proximal phalanx
fracture
Finger Injury – Management
Assess neurovascular status
Splint
Apply cold pack and elevate
Lower-Extremity Injuries
Compared with upper-extremity
injuries, lower-extremity injuries are:
Associated with greater wounding forces
and more significant blood loss than
upper-extremity injuries
More difficult to manage in the patient with
multiple injuries
May be life threatening
Femur fracture
Pelvic fracture
Pelvic Fracture
 Blunt or penetrating injury to the pelvis may result in:
 Fracture
 Severe hemorrhage
 Associated injury to the urinary bladder and urethra
 Deformity may be difficult to see
 Suspect injury to the pelvis based on:
 Mechanism of injury
 Presence of tenderness on palpation of the iliac crests
Pelvic Fracture
Management
High-concentration oxygen administration
Treatment for shock
Full body immobilization on a long spine
board (adequately padded for comfort)
Regular monitoring of vital signs
Hip Injury
 Commonly occurs in older adults because of
a fall
Also occurs in younger patients from major
trauma
 If the hip is fractured at the femoral head and
neck, the affected leg is usually shortened
and externally rotated
 Dislocations of the hip are usually evidenced
by a shortened and rotated leg
Hip Injury – Management
 Assessment of neurovascular status
 Splinting with a long spine board and
generously padding patient for comfort
during transport
 Slight flexion of the knee or padding beneath
the knee may improve comfort
 Frequent monitoring of vital signs
Femur Injury
 Usually results from major trauma (motor
vehicle crashes and pedestrian accidents)
 Fairly common result of child abuse
 Fractures are usually evident from the
powerful thigh muscles producing overriding
of the bone fragments
 Patient generally has a shortened leg that is
externally rotated and mid-thigh swelling
from hemorrhage
 Bleeding may be life-threatening
Femur Injury – Management
High-concentration oxygen
administration
Treatment for shock
Assessment of neurovascular status
Application of a traction splint
Regular monitoring of vital signs
Knee and Patella Injury
 Fractures to the knee and fractures and
dislocations of the patella commonly result
from:
Motor vehicle crashes
Pedestrian accidents
Contact sports
Falls on a flexed knee
 The relationship of the popliteal artery to the
knee joint may lead to vascular injury,
particularly with posterior dislocations
Knee and Patella Injury –
Management
 Assessment of neurovascular status
 Splinting in the position found with rigid or
formable splint that effectively immobilizes
the hip and ankle
 Application of a cold pack and elevation, if
possible
Tibia and Fibula Injury
May result from direct or indirect
trauma or twisting injury
If associated with the knee, popliteal
vascular injury should be suspected
Management
Assessment of neurovascular status
Splinting with a rigid or formable splint
Application of a cold pack and elevation
Foot and Ankle Injury
Fractures and dislocations of the foot
and ankle may result from:
Crush injury
Fall from a height
Violent rotary force
Patient usually complains of point
tenderness and is hesitant to bear
weight on the extremity
Foot and Ankle Injury –
Management
Assessment of neurovascular status
Application of a formable splint, such
as a pillow, blanket, or air splint
Application of a cold pack
Elevation
Phalanx Injury
 Often caused by “stubbing” the toe on an
immovable object
 Usually managed by buddy taping the toe to
an adjacent toe for support and
immobilization
 Management
Assessment of neurovascular status
Buddy splinting
Application of cold pack
Elevation
Management
 As a rule, fractures and dislocated joints should be
immobilized in the position of injury and the patient
transported to the emergency department for
realignment (reduction)
 If transport is delayed or prolonged and circulation is
impaired, an attempt to reposition a grossly
deformed fracture or dislocated joint should be made
 The elbow should never be manipulated in the
prehospital setting
Method
Handle the injury carefully
Apply gentle, firm traction in the
direction of the long axis of the
extremity
If there is obvious resistance to
alignment, splint the extremity without
repositioning
Realignment Guidelines
 Only one attempt at realignment should be
made in the prehospital setting
 Only if there is severe neurovascular
compromise (e.g., extremely weak or absent
distal pulses)
 May consult OLMC
 Manipulation (if indicated) should be
performed as soon as possible after the
injury
Realignment Guidelines
Should be avoided in the presence of
other severe injuries
If not contraindicated by other injuries,
consider use of analgesics for the
realignment procedure
Assess and document pulse,
sensation, and motor function before
and after manipulating any injured
extremity or joint
Spinal Injuries
Common MOI’s
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Hyperextension
Flexion
Compression
Lateral
Distraction
Penetration
Flexion-Rotation
Traditional Spinal Assessment
Criteria
 Traditional criteria have focused on
mechanism of injury (MOI) with spinal
immobilization considerations for two specific
patient groups:
Unconscious accident victims
Any patients with a “motion” injury
 Covers all patients with a potential for spinal
injury
Not always practical in the prehospital setting
Prehospital Assessment
 Prehospital assessment can be enhanced by applying clear,
clinical criteria for evaluating spinal cord injury that includes the
following signs and symptoms (in the absence of other injuries,
altered mental status, or use of intoxicants):
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Pain
Tenderness
Painful with or without movement
Deformity
Cuts/bruises over spinal area
Paralysis
Paresthesias
Weakness
Priaprism (usually a total transection of the cord)
SOB with very little Chest Expansion
Incontinence
MOI or Nature of Injury
 When determining mechanism of injury in a
patient who may have spinal trauma, classify
the MOI as:
Positive
Negative
Uncertain
 When combined with clinical criteria for
spinal injury, can help identify situations in
which spinal immobilization is appropriate
Positive MOI
 Forces exerted on the patient are highly
suggestive of spinal cord injury
 Always require full spinal immobilization
 Examples:
High-speed motor vehicle crashes
Falls greater than three times the patient’s height
Violent situations occurring near the patient’s
spine
Sports injuries
Other high-impact situations
Positive MOI
In the absence of signs and symptoms
of SCI, some medical-direction
agencies may recommend that a
patient with a positive MOI not be
immobilized
Recommendations will be based on the
paramedic’s assessment when:
Patient history is reliable
There are no distraction injuries
Negative MOI
 Includes events where force or impact does
not suggest a potential for spinal injury
In the absence of SCI signs and symptoms, does
not require spinal immobilization
 Examples:
Dropping an object on the foot
Twisting an ankle while running
Isolated soft tissue injury
Uncertain MOI
 When the impact or force involved in the
injury is unknown or uncertain, clinical
criteria must be used to determine need for
spinal immobilization
 Examples:
Tripping or falling and hitting the head
Falls from 2 to 4 feet
Low-speed motor vehicle crashes (“fender
benders”)
Assessment of Uncertain MOI
 Ensure that the patient is “reliable”
Reliable patients are calm, cooperative, sober,
alert, and oriented
 Examples of “unreliable” patients:
Acute stress reactions from sudden stress of any
type
Brain injury
Intoxicated
Abnormal mental status
Distracting injuries
Problems communicating
Spinal Injury
 Frequent causes of spinal trauma:
Axial loading
Extremes of flexion, hyperextension, or
hyperrotation
Excessive lateral bending
Distraction
 May result in stable and unstable injuries
based on:
Extent of disruption to spinal structures
Relative strength of the structures remaining
intact
Axial Loading (Vertical
Compression)
Results when direct forces are
transmitted along the length of the
spinal column
May produce compression fracture or a
crushed vertebral body without SCI
Most commonly occur at T12 to L2
Flexion, Hyperextension, and
Hyperrotation
Extremes in flexion, hyperextension, or
hyperrotation may result in:
Fracture
Ligamentous injury
Muscle injury
Spinal cord injury is caused by
impingement into the spinal canal by
subluxation of one or more cervical
vertebrae
Lateral Bending
Excessive lateral bending may result in
dislocations and bony fractures of
cervical and thoracic spine
Occurs as a sudden lateral impact moves
the torso sideways
Initially, head tends to remain in place
until pulled along by the cervical
attachments
Distraction
May occur if the cervical spine is
suddenly stopped while the weight and
momentum of the body pull away from
it
May result in tearing and laceration of the
spinal cord
Less Common Mechanisms of
Spinal Injury
Blunt trauma
Electrical injury
Penetrating trauma
Classifications of Spinal Injury
Sprains
Strains
Fractures
Dislocations
Sacral fractures
Coccygeal fractures
Cord injuries
Spinal Injuries
All patients with suspected spinal
trauma and signs and symptoms of SCI
should be immobilized
Avoid unnecessary movement
An unstable spine can only be ruled out
by radiography or lack of any potential
mechanism for the injury
Assume Spinal Injury:
 Significant trauma and use
of intoxicating substances
 Seizure activity
 Complaints of pain in the
neck or arms (or paresthesia
in the arms)
 Neck tenderness on
examination
 Unconsciousness because
of head injury
 Significant injury above the
clavicle
 A fall more than three times
the patient's height
 A fall and fracture of both
heels (associated with
lumbar fractures)
 Injury from a high-speed
motor vehicle crash
Spinal Injury
Damage produced by injury forces can
be further complicated by:
Patient's age
Preexisting bone diseases
Congenital spinal cord anomalies
Spinal cord neurons do not regenerate
to any great extent
Hyperflexion Sprains and Strains
Hyperflexion sprains
Occur when the posterior ligamentous
complex tears at least partially
Hyperextension strains (whiplash)
Common in low-velocity, rear-end
automobile collisions
Signs and symptoms
Management
Fractures and Dislocations
Most frequently injured spinal regions
in descending order:
C5-C7
C1-C2
T12-L2
Of these, the most common are wedgeshaped compression fractures and
"teardrop" fractures or dislocations
Sacral and Coccygeal
Fractures
Most serious spinal injuries occur in the
cervical, thoracic, and lumbar regions
Patients frequently complain that they
have “broken their tailbone”
Experience moderate pain from the
mobile coccyx
Sacral and Coccygeal
Fractures
 Fractures through the foramina of S1 and S2
are fairly common and may compromise
several sacral nerve elements
May result in loss of perianal sensory motor
function and in bladder and sphincter
disturbances
 Sacrococcygeal joint may also be injured
because of direct blows and falls
Classification of Cord Injuries
Primary injuries - occur at time of
impact
Secondary injuries - occur after the
initial injury and can include:
Swelling
Ischemia
Movement of bony fragments
Cord Injuries
The spinal cord can be concussed,
contused, compressed, and lacerated
Severity of these injuries depends on:
Amount and type of forced that produced
them
Duration of the injury
Cord Lesions
Lesions (transections) of the spinal
cord are classified as complete or
incomplete
Complete Cord Lesions
 Usually associated with spinal fracture or dislocation
 Total absence of pain, pressure, and joint sensation
and complete motor paralysis below the level of
injury
 Results in:
 Quadriplegia
 Injury at the cervical level
 Loss of all function below injury site
 Paraplegia
 Injury at the thoracic or lumbar level
 Loss of lower trunk only
Complete Cord Lesions
 Autonomic dysfunction may be associated
with complete cord lesions
 Manifestations of autonomic dysfunction:
Bradycardia
Hypotension
Priapism
Loss of sweating and shivering
Poikilothermy (look it up!)
Loss of bowel and bladder control
Incomplete Lesions
Central cord syndrome
Commonly seen with hyperextension or
flexion cervical injuries
Characterized by greater motor
impairment of the upper than lower
extremities
Signs and symptoms
Paralysis of the arms
Sacral sparing
Incomplete Lesions
 Anterior cord syndrome
Usually seen in flexion injuries
Caused by:
 Pressure on the anterior aspect of the spinal cord by a
ruptured intervertebral disk
 Fragments of the vertebral body extruded posteriorly
into the spinal canal
 Signs and symptoms
Decreased sensation of pain and temperature
below level of lesion
Intact light touch and position sensation
Paralysis
Incomplete Lesions
 Brown-Sequard syndrome
A hemi-transection of the spinal cord
May result from:
 A ruptured intervertebral disk
 Encroachment on the spinal cord by a fragment of
vertebral body, often after knife or missile injuries
In the classic presentation, pressure on half the
spinal cord results in:
 Weakness of the upper and lower extremities on
ipsilateral side
 Loss of pain and temperature on contralateral side
Assessment
Priorities:
Scene survey
Assessment of airway, breathing, and
circulation
Preservation of spinal cord function and
avoiding secondary injury to the spinal
cord
Assessment
Prevent secondary injury that could
result from:
Unnecessary movement
Hypoxemia
Edema
Shock
Prehospital Goals
Maintain a high degree of suspicion for
spinal injury
Scene survey
Kinematics
History of the event
Provide early spinal immobilization
Oxygen administration
Rapidly correct any volume deficits
Neurological Examination
 After managing life-threatening problems
encountered in the initial assessment,
perform a neurological exam
May be done at the scene or en route to the
hospital if the patient requires rapid transport
Document findings
 Components of neurological examination:
Motor and sensory findings
Reflex responses
Dermatomes
 Dermatomes correspond to spinal nerves
 The following landmarks may be useful for a quick
sensory evaluation in the prehospital setting:
 C2 to C4 dermatomes provide a collar of sensation around
the neck and over the anterior chest to below the clavicles
 T4 dermatome provides sensation to the nipple line
 T10 dermatome provides sensation to the umbilicus
 S1 dermatome provides sensation to soles of the feet
Other Methods of Evaluation
Visual inspection may indicate
presence of injury and its level
Transection of the cord above C3 often
results in respiratory arrest
Lesions that occur at C4 may result in
paralysis of the diaphragm
Transections at C5-C6 usually spare the
diaphragm and permit diaphragmatic
breathing
Spinal Injury
Absence of neurological deficits does
not rule out significant spinal injury
If a spinal injury is suspected, the patient's
spine must be protected
Patient's ability to walk should not be a
factor in determining need for spinal
precautions
Spinal Immobilization
 Primary goal is to prevent further injury
Treat the spine as a long bone with a joint at
either end (the head and pelvis)
Always use “complete” spinal immobilization
 Spinal immobilization begins in the initial
assessment
Must be maintained until the spine is completely
immobilized on a long backboard
Spinal Stabilization
Techniques
Immediately on recognizing a possible
or potential spine injury, manually
protect the patient's head and neck
Head and neck must be maintained in line
with the long axis of the body
Rigid Cervical Collars
 Designed to limit (not stop) motion of the
head and neck
 Available in many sizes (or are adjustable)
 Choosing the appropriate size reduces flexion or
hyperextension
 Must not inhibit patient's ability to open his or her
mouth or to clear his or her airway in case of
vomiting
 Must not obstruct airway passages or ventilations
 Should be applied only after the head has been
brought into a neutral in-line position
C-Collars
 To measure the collar
 Check the distance from the angle of the
jaw to the top of the Trapezius muscle
with your hand
 Match the appropriate finger width to the
C-collar and select appropriate size
Short Spine Boards
 Used to splint the cervical and
thoracic spine
 Vary in design and are
available from many equipment
manufacturers
 Generally used to provide
spinal immobilization in
situations in which the patient
is in a sitting position or a
confined space
 After short spine board
immobilization, the patient is
transferred to a long spine
board for complete spinal
immobilization
Rapid Extrication
Steps may vary depending on:
Size and make of the vehicle
Patient’s location inside the vehicle
Procedure
Long Spine Board
Available in a variety of types including:
Plastic and synthetic spine boards
Metal alloy spine boards
Vacuum mattress splints
Split litters (scoop stretchers) that must be
used with a long spine board
Long Spine Board - Supine
Patient
 Immobilizing the torso to a long spine board must
always precede immobilization of the head
 Torso must not be allowed to move up, down, or to
either side
 Place straps at the:
 Shoulders or chest
 Around the mid-torso
 Across the iliac crests to prevent movement of the lower
torso
 After immobilization of torso, immobilize head and
neck in a neutral, in-line position
Long Spine Board - Supine
Patient
Noncompressible padding should be
added as needed before securing the
head
Padding (if needed) should be firm and
extend the full length and width of the
torso from the buttocks to the top of the
shoulders
Long Spine Board - Supine
Patient
Children have proportionally larger
heads than adults
May require padding under the torso to
allow the head to lie in a neutral position
on the board
Long Spine Board - Supine
Patient
Secure the head to the device by
placing commercial pads or rolled
blankets on both sides of the head and
securing with:
Included straps
2 to 3 inch tape strips
You must be comfortable with both types!
Tape
 When apply tape, use a minimum of 3 complete
wraps while apply gentle but firm traction on the tape
 Use a continuous loop (do not break at each
section)
 Order of taping
 Secure thoracic cage
 Hands/arms free for the conscious patient
 Hands/arms secured for the unconscious patient
 Secure pelvis
 Secure lower extremities (thighs and lower limbs)
 Secure head
Straps
 Need a minimum of 3 straps (4 or more is preferred)
 Straps should be applied in same order as tape
 Use cross over technique
 Right shoulder to left hip
 Left shoulder to right hip
Standing Take Down
Used to immobilize the standing patient
Should be done in a quick efficient
manor
Techniques…
Two person
Three person
Immobilizing Pediatric Patients
 Prehospital care should include:
 Manual in-line immobilization
 Rigid cervical collar
 Long spinal immobilization device
 Immobilization devices available from various
equipment manufacturers
 If unavailable, adult long spine boards may be used
for full spinal immobilization
Helmet Issues
 Purpose of helmets is to protect the head
and brain, not the neck
Leaves the cervical spine vulnerable to injury
 Types of helmets
Full-face or open-face designs
 Used in motorcycling, bicycling, rollerblading, and other
activities
Helmets designed for sports such as football and
motor-cross
Helmet Issues
 When determining the need to remove a
helmet consider:
Athletic trainers may have special equipment
(and training) to remove face-pieces from sports
helmets
 Allows easier access to the patient’s airway
Sports garb (e.g., shoulder pads) could further
compromise the cervical spine if only the helmet
were removed
Firm fit of a helmet may provide firm support for
patient’s head
Helmet Removal
Removing a helmet from an injured
patient in the prehospital setting (vs. inhospital removal) is controversial
If the patient’s airway cannot be
adequately accessed or secured, or if the
helmet hinders emergency care
procedures, the helmet should be
removed in the field