Musculosketal Trauma

Musculosketal Trauma Chapter 30

Objectives • Review Musculoskeletal System • Injuries to bones and joints • Critical Fractures • Basics of Splinting

The Muscles • Voluntary – control at will • Voluntary make deliberate movement like walking, chewing, and frowning • Attached to the skeleton at one or both ends • Form the major muscle mass of the body • Tissue contracts when stimulated by a nerve impulse • Give out bodies their distinctive shapes

Muscles can be injured in many ways • Broken fibers from overextension • Bruises • Crushing • Cuts • Tears • Painful swelling and weakness

Tendons and Ligaments • Glue that holds the body together • Composed of specialized connective tissue • Tendons – connect muscle to bone • Ligaments – connect bone to bone • Can be crushed, bruised, cut or torn

Cartilage • Extension of the bone • Comprised of connective tissue • Strong, smooth, flexible, compressible, slippery substance • Found at the point of articulation of two bones • Protects bones in motion from friction • Acts as shock absorber between bone surfaces • Leads to joint pain when injured

Joints allow for types of motion • Flexion – Bending, moves the extremity toward the body • Extension – Moves extremity away from body • Adduction – Toward midline of the body • Abduction – Movement of a body part away from the midline • Rotation – Turning along the axis of the bone or joint • Circumduction – Movement through an arc of a circle or in a circular motion from a central point

The Skeletal System Upper Extremity – shoulder girdle, arm, forearm, hand • Clavicle (collar bone) • Scapula (shoulder) • Humerus (upper arm) • Radius (lower arm) • Ulna (includes olecranon, lower arm and elbow • Carpal bones (wrist) • Metacarpals (hand) • Phalanges (fingers)

Lower extremity Pelvis, thigh, leg, foot • Pelvis (including ilium, ischium, pubis) • Femur (thigh) • Patella (kneecap) • Tibia (lower leg) • Fibula (lower leg) • Calcaneus (heel) • Tarsals (ankle) • Metatarsals (foot) • Phalanges (toes)

Types of Injuries • Fracture • Strain • Sprain • Dislocation • General injury considerations

Fractures A break in the continuity of a bone Caused by direct, indirect, or twisting force Open – Associated with an open wound Closed – Skin is not broken

Fractures Pathologic Fracture Type can only be distinguished by x-ray • Hairline – Small crack in bone, does not create instability • Pathologic – Result of a degenerative disease such as osteoporosis • Various complications • Hemorrhage from the bone • Instability of the extremity • Surrounding tissue damage • Infection (open fracture) • Interruption of distal blood supply Epiphyseal Fracture

Strain • Injury to a muscle or tendon • Often due to overextension (overstretching) • Can be caused by extreme muscle stress or fatigue associate with overuse • No edema or discoloration • Pain or weakness with use of the muscle

Sprain • Injury to a joint capsule • Damage to or tearing of the connective tissue • Usually involves ligaments • Usually occurs in shoulder, knee, or ankle • Immediate pain and tenderness, followed by inflammation and swelling

Dislocation • Displacement of bone from normal position in joint • Caused by joint being forced beyond normal range of motion • Obvious deformity and swelling; pain and tenderness • May occur at shoulder, elbow, wrist, hand, hip, knee, ankle, or foot

General Injury Considerations • Similar signs and symptoms; swelling, pain, or deformity • Usually associated with external forces (fall, vehicle collision) • May occur through degenerative disease, particularly in elderly patients • Force may cause injuries to surrounding soft tissues and other body areas

Mechanism of Injury • Direct force – injury occurs at the point of impact • Indirect force – force impacts on one end of a limb, causing injury some distance away from point of impact • Twisting force – One part of extremity remains stationary while the rest twists

Critical Fractures: Femur Symptoms • Bone bleeds heavily – Up to 1.5 liters of blood • Tension on thigh muscles is lost so thigh diameter increases, allowing more blood to housed within thigh Goals of Treatment • Immobilize bone ends • Reduce bleeding Effect of traction splint • Bone ends are realigned, preventing further injury and reducing pain • Diameter of thigh is decreased, allowing less blood to accumulate

Critical Fractures: Pelvis • Bone itself bleeds heavily – Up to 2 liters of blood • Application of PASG/MAST will stabilize fracture and may help tamponade bleeding pelvis • Whatcom Co. Protocol page 17, recommends the pelvic sling in place of the PASG/MAST

Assessment based approachBone or Joint Injuries Scene size-up/Primary Assessment • BSI • Consider MOI • Ask bystanders what caused the injury • Imagine the forces to which the patient’s body was subjected. • Check for signs of severe hemorrhage • Look for signs of shock and treat • If injury has caused a life-threatening condition, immobilize injured extremity and transport immediately

Secondary Assessment • If patient has life-threatening injury, not directly related to injury, initiate transport, immobilize enroute to hospital if time and patient’s condition allows • Patient is responsive and oriented, inspect and gently palpate bone or joint • Be gentle and reassuring • Check injury site for signs/symptoms of injury (deformity, contusions, tenderness) • Check for Crepitis • Assess baseline vitals and obtain a history Greenstick Fracture

Secondary Assessment Evaluate the 6 “Ps” • Pain • Pallor • Paralysis – May indicate nerve, muscle, tendon or ligament damage • Paresthesia – May indicate nerve damage (Numbness, prickly feeling, or tingling) • Pressure – May indicate damaged tissue or internal blood loss • Pulse – Decreased or absence of distal pulse may indicate arterial damage

Emergency Care • Life-threatening, immobilize injured extremity during primary/secondary assessments if appropriate and does not delay transport • If patient has other life-threatening condition, initiate transport, then immobilize enroute • Immobilize suspected fracture • BSI • Oxygen • Maintain in-line stabilization if spine injury suspected • Splint bone and joint • Apply cold packs to painful, swollen, or deformed extremity • Elevate extremity (No spine injury) • Transport • Reassess vital signs, splinting • Check distal pulses, motor function and sensation after immobilizing

General rules to Splinting • Before and after splinting, assess pulse, motor function, and sensation distal to the injury • Immobilize joints above and below a long bone injury • Remove or cut away clothing and jewelry around the injury site • Cover all wounds with sterile dressings and gently bandage before splinting • If there is severe deformity or the distal extremity is cyanotic or lacks pulses, align injured limb with gentle manual traction before splinting

General rules to Splintingcontinued • Never intentionally replace protruding bones or push them back below the skin • Pad each splint to prevent pressure and discomfort • Apply the splint before trying to move the patient • When in doubt, splint the injury • If patient shows signs of shock, do not apply splint first; align patient in normal anatomical position, treat for shock, transport immediately

Splinting equipment Rigid splints • Commercially manufactured • Made of wood, wood fiber, plastic or cardboard • Designed to fit specific limbs, or can be molded to fit any appendage • May come with washable pads

Pressure (air/pneumatic) splints • Soft and pliable before inflation; rigid once applied and inflated • Cannot be sized • May impair circulation • May interfere with ability to assess pulses • May lose or gain pressure with changes in temperature/altitude • Seek medical direction regarding use

Traction Splints • Provide a counterpull that alleviates pain, reduces blood loss, and minimizes further injury • Purpose is to immobilize bone ends, reduce diameter of thigh, and prevent further injury • Many types available

Formable splints & Vacuum splints Formable • Rigid but made to be shaped to fit deformed extremity • Can fixed in place with cravats or Velcro • Typically composed of wire, aluminum or other flexible metal Vacuum Splint • Soft and pliable • Easily formed to deformed extremities • When air is sucked out, splint becomes rigid

Sling and swathe • Provides stability to injured shoulder, elbow or upper humerus • Sling support arm; swathe holds arm against chest • Minimizes pain and further injury

Spine board • Considered a full body splint • Use in cases of critical injury to provide stability where extremity fractures cannot be splinted at scene

Improvised splints • Light in weight but firm and rigid • As wide as thickest part of fractured limb • Long enough to extend past joints and prevent movement • Padded well so inner surfaces are not in contact with skin • Possible materials include cane, cardboard, umbrella, pillow, blanket

Hazards of Improper splinting • Compression of nerves, tissues, and blood vessels • Delay in patient’s transport • Reduction of distal circulation • Aggravation of bone or joint injury • Aggravation or cause of damage to tissue, nerves, blood vessels, or muscles

Splinting long bone injuries • Look for exposed bone ends, joints locked in position, paresthesia (tingling), paralysis, and pallor • Assess pulse, motor function, and sensory below the injury site • If limb severely deformed, cyanotic, or lacks distal pulses, align with gentle traction

Splinting joint injuries • Look for paresthesia or paralysis • Assess the pulse, motor and sensory function below the injury site • If distal extremity is cyanotic, or lacks distal pulses, align with gentle traction; stop if pain or crepitus increases

Traction Splinting • Use for fractured femur • Reduces diameter of thigh • Decreases space in which bleeding can occur • Do not use in the following instances; • Injury is within one to two inches of the knee or ankle • Knee itself is injured • Hip is injured • Pelvis is injured • There is partial amputation or avulsion with bone separation

Splinting Specific Injuries • Special techniques may be applied to the splinting of suspected bone and joint injuries to specific sites • Review splinting techniques for the shoulder, upper arm, elbow, forearm, wrist, hand, fingers, pelvis, hip, thigh, knee, lower leg, ankle, and foot

Pelvic Fracture • PASG can splint pelvis and decrease compartment size to reduce bleeding • Commercial pelvic splint is another method • Improvised pelvic wrap may be applied if necessary • Fold a sheet lengthwise to 8” width • Slide it under the small of the back, then down under the pelvis until centered. Ends of the sheet must be of equal length on both sides of patient • Cross tail ends over patient and twist until sheet is tightly secured around pelvis • Tuck sheet ends under patient or tie into square knot • Place patient on backboard or rigid device

Compartment Syndrome • May occur when fracture or injury to an extremity has occurred • May occur in buttock or abdomen • Occurs when pressure in space around capillaries exceed pressure needed to perfuse tissues; blood flow is cut off and cells become hypoxic • Usually develops over time as edema around injured area increases • Commonly associated with fractures, bleeding from trauma, crush injuries, and high-energy trauma

Compartment Syndrome Signs/Symptoms • Severe pain or burning sensation • Decreased strength in extremity • Paralysis of extremity • Pain with movement • Extremity feeling hard to palpitation • Distal pulses, motor, and sensory function possibly normal Treatment • Immobilize and splint affected extremity • Elevate extremity and apply cold pack to ice • Transport ASAP

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Musculosketal Trauma