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Chapter 7
Musculoskeletal Trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Introduction to Musculoskeletal
Trauma
Anatomy and Physiology of the
Musculoskeletal System
Pathophysiology of the
Musculoskeletal System
Musculoskeletal Injury Assessment
Musculoskeletal Injury Management
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction to Musculoskeletal
Injuries
Millions of Americans experience
annually
Multiple MOI
– Falls, crashes, violence, etc.
– Multi-system trauma
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of the
Musculoskeletal System
Skeletal Tissue and Structure
– Gives the body its structural form
– Protects vital organs
– Promotes efficient movement despite the
forces of gravity
– Stores salts and other materials needed
for metabolism
– Produces red blood cells
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal System
Bone Structure
– Diaphysis
– Epiphysis
End of a long bone
– Metaphysis
Between epiphysis and
diaphysis
Growth plate
– Medullary canal
Contains bone marrow
– Periosteum
Fibrous covering of diaphysis
– Cartilage
Connective tissue that
provides a smooth articulation
surface for other bones
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of the
Musculoskeletal System
Joint Structure
– Joint
Where bones interact
– Synarthrosis
A joint that does not permit movement
– Diarthroses (synovial joints)
Monaxial: hinge or pivot joints
Biaxial: gliding, sliding, or saddle joints
Triaxial: ball and socket joints
– Ligaments
– Joint capsule
Synovial fluid
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Joint Structure (1 of 2)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Joint Structure (2 of 2)
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of the
Musculoskeletal System (1 of 3)
Skeletal Organization
– 206 bones
– Axial skeleton
Head, thorax, and spine
– Appendicular skeleton
Upper extremities
Lower extremities
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of the
Musculoskeletal System (2 of 3)
Bone Aging
– Birth to adult (18–20)
Transition from flexible to firm bone
– Adult to elderly (40+)
Reduction in collagen matrix and calcium salts
Diminution of bone strength
Spinal curvature
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology of the
Musculoskeletal System (3 of 3)
Types of Muscles
– Smooth
– Striated
– Cardiac
Muscular Tissue and
Structure
– 600 muscle groups
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Muscles
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal System
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of the
Musculoskeletal System (1 of 5)
Muscular Injury
Contusion
Compartment Syndrome
Penetrating Injury
Fatigue
Muscle Cramp
Muscle Spasm
Strain
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of the
Musculoskeletal System (2 of 5)
Joint Injury
– Sprain
– Subluxation
– Dislocation
Bone Injury
–
–
–
–
Open fracture
Closed fracture
Hairline fracture
Impacted fracture
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of the
Musculoskeletal System (3 of 5)
Pediatric Considerations
– Flexible nature
Geriatric Considerations
– Osteoporosis
Pathological Fractures
– Pathological diseases
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of the
Musculoskeletal System (4 of 5)
General Considerations with
Musculoskeletal Injuries
– Neurological compromise
– Decreased stability
– Muscle spasm
Bone Repair Cycle
– Osteocytes produce osteoblasts
– Deposition of salts
– Increasing strength of matrix
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Pathophysiology of the
Musculoskeletal System (5 of 5)
Inflammatory and Degenerative Conditions
– Bursitis
– Tendinitis
– Arthritis
Osteoarthritis
Degenerative
Rheumatoid arthritis
Chronic, systemic, progressive, debilitating
Gout
Inflammation of joints produced by accumulation of uric
acid crystals
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury
Assessment (1 of 2)
Scene Size-up
Initial Assessment
– Categories of urgency
Life- and limb-threatening injury
Life-threatening injury and minor musculoskeletal injury
Non-life-threatening injuries but serious musculoskeletal injuries
Non-life-threatening injuries and only isolated minor musculoskeletal
injuries
Rapid Trauma Assessment
– Only press on pelvis if no clinical signs of injury are present such
as pain.
Focused H&P
– 6 Ps: Pain, Pallor, Paralysis, Paresthesia, Pressure, Pulses
Detailed Physical Exam
Ongoing Assessment
Sports Injury Consideration
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury
Assessment (2 of 2)
Scene Size-up
– Clues to specific injuries.
– Pelvic fractures or bilateral femur
fractures are “Load and Go.”
– Control major bleeding.
– History may suggest other injuries.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Detailed Exam of Extremities
Deformity
Contusions
Abrasions
Penetrations
Burns
Tenderness
Lacerations
Swelling
Also check PMS.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury
Management (1 of 2)
General Principles
–
–
–
–
Protecting open wounds
Positioning the limb
Immobilizing the injury
Checking neurovascular function
Pulse
Palpate
Utilize pulse oximetry
Motor
Sensation
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury
Management (2 of 2)
Splinting Devices
– Rigid splints
– Formable splints
Vacuum splints
Air Splints
– Soft splints
– Traction splints
– Other splinting aids
Cravats or Velcro splints
Fracture Care
Joint Care
Muscular and Connective Tissue Care
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury Management
Care for Specific Fractures (1 of 4)
Pelvis
– Scoop stretcher
– Pelvic sling device
PASG as a reserve device only
– Fluid resuscitation
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury Management
Care for Specific Fractures (2 of 4)
Femur Fractures
– Traction splints
Contraindicated in hip/knee injuries
– PASG
– High-force injury
– High potential for shock
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury Management
Care for Specific Fractures (3 of 4)
Tibia-Fibula Fractures
– Frequently open fractures.
– Cover bone ends with moist dressing.
– Depending on level of fracture, use:
Rigid splint
Air splint
Pillow
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury Management
Care for Specific Fractures (4 of 4)
Clavicle
Most frequently fractured bone in the body
Transmitted to 1st and 2nd rib
Alert for lung injury
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury
Management
Care for Specific Joint Injuries
–
–
–
–
–
–
–
–
Hip
Knee
Ankle
Foot
Shoulder
Elbow
Wrist/Hand
Finger
Be alert for
neurological
compromise.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hip Fractures
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 mattress if available.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hip Dislocation
Orthopedic emergency
Posterior dislocation most common
Hip flexed and leg rotated internally
Severe pain on attempts to straighten
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Hip Dislocation Management
Splint in most comfortable position.
Document sensation and pulse.
Prompt transport.
Be alert for associated knee injuries or
fractures.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Knee Fracture or Dislocation
Orthopedic emergency
Frequently causes vascular injury
Dislocation associated with 50% rate
of amputation of leg
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Knee Fracture or Dislocation
Management
Obvious dislocation without distal
pulse:
– Apply gentle traction along the long axis
of the joint.
If gentle traction does not restore the
pulse:
– Splint in place.
Prompt transport.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Foot or Hand Injury
Common industrial injury.
Often disabling.
Rarely life threatening.
Splint foot with pillow.
Splint hand in position of function.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Shoulder Injuries
AC Separation
– Sling and swathe.
Shoulder Dislocation
– Use pillow with sling and swathe.
Fracture
– Use sling and swathe.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Elbow Injury
Fracture or dislocation may cause
neurovascular injury.
Splint in position found.
Transport promptly.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Forearm/Wrist Injury
Rigid Splint
– Keep hand in “position of function.”
Air Splint
– May be hard to reassess circulation.
Pillow
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury
Management
Soft and Connective Tissue Injuries
– Tendon
– Ligament
– Muscle
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury Management
Medications (1 of 4)
Nitrous Oxide
– 50% O2:50% N2O
– Non-explosive
– Effects dissipate in 2–5
minutes
– Easily diffused into airfilled spaces in body
– Dose
Inhaled and self
administered
– Onset
1–2 minutes
Diazepam
–
–
–
–
Benzodiazepine
Antianxiety
Analgesic
Dose
5–15 mg titrated
– Onset
10–15 minutes
– Duration
15–60 minutes
– Counter agent
Flumazenil
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury Management
Medications (2 of 4)
Morphine Sulfate
– Opiate alkaloid.
– Reduces vascular volume and cardiac
preload.
– Do not administer to hypovolemic
patients.
– Dose:
2mg IVP slow
– Counter agent:
Narcan
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury Management
Medications (3 of 4)
Meperidine
– Demerol
– Narcotic analgesic
– Dose
50–100 mg
– Counter Agent
Narcan
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury Management
Medications (4 of 4)
Sublimaze
–
–
–
–
Fentanyl
Synthetic opioid
Equivalent to morphine
Dose
25–50 mg SIVP followed by an additional 25 mg as needed
– Onset
Less than a minute
– Duration
3–6 hours
– Considerations
If given too rapidly, chest wall rigidity may ensue, leading to
respiratory compromise.
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Musculoskeletal Injury
Management
Other Injury Considerations
–
–
–
–
Pediatric musculoskeletal injury
Athletic musculoskeletal injury
Patient refusals and referral
Psychological support
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Introduction to Musculoskeletal
Trauma
Anatomy and Physiology of the
Musculoskeletal System
Pathophysiology of the
Musculoskeletal System
Musculoskeletal Injury Assessment
Musculoskeletal Injury Management
Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ