Download No Slide Title

Musculoskeletal Trauma
EMS Professions
Temple College
Incidence/Mortality/Morbidity
Occur in 70-80% of all multi-trauma
patients
 Blunt or Penetrating
 Upper extremity rarely life-threatening

– may result in long-term impairment

Lower extremity associated with more
severe injuries
– possibility of significant blood loss
– femur, pelvic injuries may pose life-threat
Incidence/Mortality/Morbidity

Problem is not just the bone injury
– Other injuries caused by the injured bone
»
»
»
»
Soft tissue
Vascular
Nervous system
Decreased function
Prevention Strategies
Sports Training
 Seat Belt use
 Child Safety Seat use
 Airbag use
 Gun Safety and Education
 Motorcycle education and protective
equipment
 Fall prevention
 Can you think of others?

Musculoskeletal System Function
 Scaffolding/Support
 Protection
of vital organs
 Locomotion
 Production of RBC
 Storage of minerals
Musculoskeletal Structures
 Skin
 Muscles
 Bones
 Tendons
 Ligaments
 Cartilage
Musculoskeletal Structures Skin
Holds all structures together
 Barrier function
 Protects underlying structures
 Subcutaneous tissue

– Fat
– Fascia

Further discussion in Soft-Tissue Trauma
Musculoskeletal Structures Muscle
Composed of specialized cells with
ability to contract
 Voluntary (Skeletal)

– Conscious control
– Allows mobility

Smooth (Bronchi, GI tract, blood vessels)
– Controlled by ANS
– Able to alter inner lumen diameter

Cardiac
– Contracts rhythmically on its own
Musculoskeletal Structures Muscle
Can only contract
 Skeletal muscle causes movement by
shortening resulting in pulling on bones
through cord like bands

Musculoskeletal Structures

Tendons
– Bands of connective tissue binding muscles to
bones

Cartilage
– Connective tissue covering the epiphysis
– Surface for articulation

Ligaments
– Connective tissue supporting joints
– Attach bone ends to each other
Bones
 Living
tissue
 Consists of cells which deposit
calcium, phosphorus on protein
matrix
 Constantly remodels itself
 Able to repair damage without
formation of scar tissue
Bones
Structural form for body
 Protection
 Point of attachment for tendons, ligaments,
cartilage and muscles
 Allows for movement
 Storage of minerals
 Produce red blood cells

Skeletal System Components

Axial Skeleton
– forms the central axis of the body
– includes skull, vertebral column, bony thorax

Appendicular Skeleton
– limbs

Pectoral girdle
– bones that attach the upper limbs to the axial
skeleton

Pelvic girdle
– paired bones of the pelvis that attach the lower
limbs to the axial skeleton and sacrum
Long Bone Anatomy

Diaphysis
– Long, narrow shaft
– Dense, compact bone

Metaphysis
– Head of bone
– Between epiphysis and diaphysis

Medullary canal
– Contains marrow
Long Bone Anatomy

Periosteum
– Outer fibrous covering
– Allows for increase in diameter
– Vascular
– Nerves

Epiphysis
– Articulated, widened end
– Allows bone to lengthen
– Cancellous bone with red blood marrow
– Weakest point in child’s bone
Joints
Points of articulation between bones
 Fused/Fibrous

– Sutures
» Between bones of skull

Synovial
– Fluid filled chamber which lubricates
articulated surfaces
– Allow for movement
» gliding, flexion, extension, abduction, adduction,
circumduction, rotation
Synovial Joints
 Ball/Socket
– Shoulder/Hip
 Hinge
– Elbow/Knees/Fingers/TMJ
 Pivot
– Between radius and ulna
 Gliding
– Bones of wrist
Fracture
Break in continuity of bone
 Closed

– Overlying skin intact

Open
– Wound extends from body surface to fracture
site
– Produced either by bones or object that caused
Fx
– Danger of infection
– Bone end not necessarily visible
Mechanism of Injury

Direct
– Break occurs at point of impact

Indirect
– Force is transmitted along bone
– Injury occurs at some point distant to point of
impact
– Femur, hip, pelvic fracture due to knees hitting
dash
Mechanism of Injury

Twisting
– Distal limb remains fixed
– Proximal part rotates
– Shearing, fracturing occur
– Football. skiing accidents

Avulsion
– Muscle and tendon unit with attached fragment
of bone ripped off bone shaft
Mechanism of Injury

Stress
– Occur in feet secondary to prolonged running
or walking

Pathological
– Result of Fx with minimal force
– Cancer, osteoporosis
Fracture Descriptions
Open vs Closed
 X-Ray descriptions

– greenstick
– oblique
– transverse
– comminuted
– spiral
– impacted
– epiphyseal
Fracture Types

Transverse
– Cuts shaft at right angle to long axis
– Often caused by direct injury

Greenstick
– Pliable bone splinters on one side without
complete break
– Occurs in children
Fracture Types

Spiral
– Fx site coils through bone like spring
– Occurs with torsion

Oblique
– Occurs at angle to long axis of shaft

Comminuted
– Bone broken into 3 or more pieces
Fracture Type

Impacted
– Bone ends jammed together
– Occurs with compression
– Frequently no loss of function
Problems Associated with
Musculoskeletal Injuries
Hemorrhage
 Interruption of Blood Supply
 Disability
 Instability
 Soft Tissue injury

Complications associated with
Fractures

Hemorrhage
– Possible loss within first 2 hours
» Tib/Fib - 500 ml
» Femur - 500 ml
» Pelvis - 2000 ml

Interruption of Blood Supply
– Compression on artery
» decreased distal pulse
– Decreased venous return
Complications associated with
Fractures

Disability
– Diminished sensory or motor function
» inadequate perfusion
» direct nerve injury

Specific Injuries
– Dislocation
– Amputation/Avulsion
– Crush Injury (soft tissue trauma discussion)
Sprains/Strains

Sprain
– tearing of ligaments surrounding joint

Strain
– overstretching of muscle or tendon
Musculoskeletal Assessment

The possibilities
– Life-threatening injuries or conditions,
including life/limb threatening musculoskeletal
trauma
– Life/Limb threatening injuries and only simple
musculoskeletal trauma
– Life/Limb threatening musculoskeletal trauma
and no other life/limb threatening injuries
– Only isolated, non-life/limb threatening injuries
Musculoskeletal Assessment

Initial Assessment
– ABCDs
– Life threats managed first
– Don’t overlook life/limb threatening
musculoskeletal trauma
– Don’t be distracted by “gross” but nonlife/limb threatening musculoskeletal injury
Musculoskeletal Assessment
With few exceptions orthopedic
injuries are not life threatening.
Do not let drama of obvious or
grossly deformed fracture distract you
from more serious problems
involving ABC’s
Musculoskeletal Assessment

The six “P”s of musculoskeletal assessment
– Pain
» on palpation
» on movement
» constant
– Pallor - pale skin or poor cap refill
– Paresthesia - “pins and needles” sensation
– Pulses - diminished or absent
– Paralysis
– Pressure
Musculoskeletal Assessment
Vascular injury should be suspected in all
Fx’s/dislocations UPO
 Evaluate with 5 P’s

– Pain
– Pallor
– Pulselessness
– Paresthesias
– Paralysis
Musculoskeletal Assessment

History of Present Injury
– Where is pain felt?
– What occurred? What position was limb in?
– Were deceleration forces involved?
– Was there direct impact?
– Has there ever been previous trauma or Fx?
Musculoskeletal Assessment

Palpation and Inspection
– Swelling/Ecchymosis
» Hemorrhage/Fluid at site of trauma
– Deformity/Shortening of limb
» Compare to other extremity if norm is questioned
– Guarding/Disability
» Presence of movement does not rule out fracture
Musculoskeletal Assessment

Palpation and Inspection
– Tenderness
» Use two point fixation of limb with palpation with
other hand.
» Tenderness tends to localize over injury site.
– Crepitus
» Grating sensation
» Produced by bones rubbing against each other.
» Do not attempt to elicit.
Musculoskeletal Assessment

Palpation and Inspection
– Exposed bones
» Fx can be open without exposed bones
– Principal danger is not to bones, but to
underlying neurovascular structures around
bone.
Musculoskeletal Assessment

Palpation and Inspection
– Distal to injury, assess:
»
»
»
»
skin color
skin temperature
sensation
motor function
– If uncertain, compare extremities
– When in doubt splint!
Musculoskeletal Assessment
Because orthopedic injuries have low
priority in multiple systems trauma, all
Fx’s may not be found in field
 Long Board

– Splints every bone and joint
– No loss of time
– Focus on critical conditions
Key Point
Orthopedic injuries are seldom immediately
life threatening.
Tend to other issues first.
Only immediately life threatening orthopedic
injury is Pelvic Fx due to potential massive
hemorrhage
Key Point
The problem is not the damage to the
bone
The problem is the damage the bone
does to the surrounding soft tissues.
Evaluate Neurovascular Function
Distally
Management - General

Immobilization Objectives
– Prevent further damage to nerves/blood vessels
– Decrease bleeding, edema
– Avoid creating an open Fx
– Decrease pain
– Early immobilization of long bone fractures
critical in preventing fat embolism
Management - General

Principles of Fracture Management
– Splint joint above, below
– Splint bone ends
– Loosely cover open fracture sites
– Neurovascular assessment
» before and after splinting
– Gentle in-line traction of long bone
» maintain normal alignment if possible
» reduction of angulated fracture site
Management - General

Principles of Fracture Management (cont)
– Position of function
– Pain management

Body Splinting
– In urgent patient, entire body is stabilized by
using a long board
– Lower extremity fractures can be splinted as
one to the long board
Management - General

Pain Management
– Avoid pain management until head/thoracic
injury is ruled out
– Appropriate for isolated musculoskeletal
injuries (fracture/sprain/dislocation)
– Underutilized
– Morphine sulfate titrated to pain relief without
compromising adequate BP and ventilations
Management - Pediatric
Green stick Fx may go unrecognized
 Fx can occur in epiphyseal plate, early
closure can prevent further growth of
affected bone
 If no explanation from patient or parents or
injury does not follow mechanism, suspect
child abuse.

Management Error
Oversight of volume loss when
evaluating pt with multiple Fx’s
Estimate blood loss at each Fx site
Evaluation of neurovascular
deficiencies in distal extremity
Dislocations
Displacement of bone end from
articulating surface at joint
 Pain or pressure is most common symptom
 Principal sign is deformity
 May experience loss of motion of joint

Dislocations
Nerves, blood vessels pass very close to
bone. Pressure on these structures can
occur
 Checking distally essential

– Pulse presence
– Pulse strength
– Sensation
Management - Dislocations

Principles of fracture/dislocation
management
– Usually splinted in position of injury
– Neurovascular assessment before, after splinting
– Attempt realignment of dislocations if
» distal circulation is impaired
» long transport
– Discontinue realignment if pain increased
significantly or resistance is encountered
– Immobilize proximal. distal joints and bones
– Analgesia, possible cold application
Sprains
Stretching. tearing of ligaments
surrounding joint
 Occur when joint is twisted beyond normal
range of motion
 Most common = Ankle

Sprain Management

Characteristics
– Pain
– Tenderness
– Swelling
– Discoloration
Typically does not manifest deformity
 Ice, compression, elevation, immobilize
 When in doubt, splint
 Consider analgesia

Strains
Tearing, stretching of musculotendonous
unit.
 Spasm, pain on active movement
 Usually no deformity, swelling
 Pain present on active movement
 Avoid active movement, weight bearing

Minor Musculoskeletal Injury
Management

Cold/Heat application
– cold best if in first 48 hours to reduce swelling
– heat best if after 48 hours to increase circulation
– no direct application to soft tissue
» wrap in towel or gauze
Minor Musculoskeletal Injury
Management

Other care
– Is immobilization/splinting needed?
– Is an X-ray needed?
– Is there a need for MD follow? ED visit?
– What type of transport is needed?
Traumatic Amputation

First priority - ABC’s
– Bleeding from stump usually not a problem

Next priority is to save limb
Traumatic Amputation
Management
Control Bleeding
 Elevate
 Apply direct pressure to stump
 Avoid tourniquet except as last resort

Traumatic Amputation - Limb
Management
Place in saline moist gauze
 Place in plastic bag
 Place bag on ice
 Do not

– Warm amputated part
– Place part in water
– Place directly on ice
– Use dry ice
Upper Extremity Fx

Proximal Humerus
– Usually from a fall on outstretched hand.
– Manage with sling, swathe
– Deltoid bulge often accentuated

Shaft of Humerus
– Usually obvious due to deformity
– Wrist drop may occur
– Vascular compromise may be present
Upper Extremity Fx

Colles Fx (silver fork)
– Distal radius
– Usually secondary to fall on outstretched hand
– Common in children
Shoulder Dislocation

Realignment
– One attempt if neurovascular compromise
– Do not attempt if associated with other severe
injuries or spine injuries
– Provide analgesia
– Pull into anatomical position

Splinting
– Be creative
– Sling, swathe if possible
– Cravats are our friends!
Hip Dislocation

Anterior
– Blow to abducted leg, external rotation of
affected extremity

Posterior
– Blow to flexed/Abducted knee
– More severe than anterior dislocation
– Associated with rupture of joint capsule,
acetabular Fx, sciatic nerve injury
Management - Hip Dislocation

Realignment
– One attempt if severe neurovascular compromise
– Do not attempt if associated with other severe
injuries
– Provide analgesia
– Steady and slow pull along shaft of femur
– If successful, “pops” into joint, sudden relief of
pain, leg can easily return to extension

Immobilization
– Flexion of hip/knee for comfort acceptable
Pelvic Fracture
Direct or indirect force
 Pelvic ring tends to break in two places
 Bone fragments can cause damage

– Major vessels
– Urinary bladder
– Rectum resulting in contamination
– Nerves (Lumbrosacral plexus or sciatic)
Pelvic Fx Management
Treat as potential critical trauma patient
 Comfortable position if possible
 Splint = Minimize movement

– Scoop stretcher
– Body to long board
– MAST for splint

Replace volume prn
– Possible 4000cc blood loss
– 2 IV of LR
Femur Fx

Femoral Neck (Hip)
– Most common in mid to late 60’s age group.
– Leg tends to rotate outward
» looks like anterior hip dislocation
– Minimal blood loss tends to occur due to joint
capsule

Management
– NO traction splint
– long board, scoop or MAST
Femur Fx

Mid-Shaft
– Result from torsion in very young or old
– High speed deceleration with impact
» Hypovolemic shock
» Fat Embolism
– Early immobilization with traction splint will
help prevent
– 1000 to 2000 cc blood loss
Femur Fx - Management
Assess for traction splint contraindications
 May use PASG, secure to long board

– Secure to opposite extremity and then to long
board (premise for the Sager splint)

Assess for :
– Soft tissue, vascular, or nerve injury
– Assess for hypovolemia
Femur Fx - Management

Traction Splints
– Used on mid-shaft femur fractures
– Do not use if suspected fracture involves
»
»
»
»
»
proximal or distal 1/3 of femur
pelvis
hip (or hip dislocation)
knee (or knee dislocation)
ankle (or ankle dislocation)
– What if time (patient instability) does not allow
for traction splint application?
Lower Extremity Fx

Patellar
– Due to direct impact

Tibia/Fibula
– High potential for:
» Open fracture
» Hemorrhage
» Infection

Calcaneal
– Results from falls (foot landing)
– High incidence of lumbar sacral compression
Management - Lower Extremity
Fx

Patellar, Tibia/Fibula, and Calcaneal
– Assess for neurovascular impairment
– Realign long bones
– Splinting possibilities
» board splint or cardboard splint
» vacuum splint
» pillow
Elbow Dislocation

Presentation
– High neurovascular traffic
– Volkmann’s contracture - ischemia secondary to
trauma causes ischemic contractions

Management
– assess for neurovascular impairment
– sling
– swathe
– analgesia and position of comfort
Knee Dislocation

Presentation
– Trauma to popliteal artery
– Many reduce spontaneously
– Knee dislocation has a 50% incidence of
associated vascular injury
– Presence of distal pulse does not rule out
vascular injury
Management - Knee Dislocation

Management
– Assess for neurovascular impairment
– One attempt at realignment if impairment or
delayed transport
– Do not realign if associated with other severe
injuries
– analgesia and position of comfort
– gentle, steady traction to move into normal
position
» success by “pop” into joint, less deformity and pain,
and increased mobility
Hemorrhage Management

Direct Pressure
– Most effective method
– Pressure bandage

Elevation
– Combination with direct pressure

Pressure Point
– Brachial, Femoral, Carotid

Tourniquet
– last resort
– rarely required
Tourniquet
Last resort, but do not wait too long.
 Use flat wide material
 BP cuff
 Close to the wound as possible
 Do not remove
 Leave in plain view
 Note time applied and clearly
communicate during transfer of care
