29: Musculoskeletal Care

1. 29: Musculoskeletal Care

2. Cognitive Objectives (1 of 2) 5-3.1 Describe the function of the muscular system. 5-3.2 Describe the function of the skeletal system. 5-3.3 List the major bones or bone groupings of the spinal column, the thorax, the upper extremities, and the lower extremities. 5-3.4 Differentiate between an open and closed painful, swollen, deformed extremity (fracture).

3. Cognitive Objectives (2 of 2) 5-3.5 State the reasons for splinting. 5-3.6 List the general rules of splinting. 5-3.7 List the complications of splinting. 5-3.8 List the emergency medical care for a patient with a swollen, painful, deformed extremity (fracture).

4. Affective Objectives 5-3.9 Explain the rationale for splinting at the scene versus load and go. 5-3.10 Explain the rationale for immobilization of the painful, swollen, deformed extremity (fracture).

5. Psychomotor Objectives 5-3.11 Demonstrate the emergency medical care of a patient with a painful, swollen, deformed extremity (fracture). 5-3.12 Demonstrate completing a prehospital care report for patients with musculoskeletal injuries.

6. Anatomy and Physiology of the Musculoskeletal System

7. Skeletal System

8. Fracture Broken bone Dislocation Disruption of a joint Sprain Joint injury with tearing of ligaments Strain Stretching or tearing of a muscle Types of Musculoskeletal Injuries

9. Mechanism of Injury • Force may be applied in several ways: Direct blow Indirect force High-energy injury Twisting force

10. 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 Fractures

11. Greenstick Fracture

12. Comminuted Fracture

13. Pathologic Fracture

14. Epiphyseal Fracture

15. Deformity Tenderness Guarding Swelling Bruising Signs and Symptomsof a Fracture (1 of 2)

16. Crepitus False motion Exposed fragments Pain Locked joint Signs and Symptomsof a Fracture (2 of 2)

17. Marked deformity Swelling Pain Tenderness on palpation Virtually complete loss of joint function Numbness or impaired circulation to the limb and digit Signs and Symptomsof a Dislocation

18. Signs and Symptoms of a Sprain • Point tenderness can be elicited over injured ligaments. • Swelling and ecchymosis appear at the point of injury to the ligaments. • Pain • Instability of the joint is indicated by increased motion.

19. Compartment Syndrome • Most commonly occurs in a fractured tibia or forearm of children • Elevated pressure within a fascial compartment • Develops within 6 to 12 hours after injury • Pain out of proportion with injury • Splint affected limb, keeping it at the level of the heart. • Provide immediate transport.

20. Severity of Injury • Critical injuries can be identified using musculoskeletal injury grading system.

21. Minor Injuries • Minor sprains • Fractures or dislocations of digits

22. Moderate Injuries • Open fractures of the digits • Nondisplaced long bone fractures • Nondisplaced pelvic fractures • Major sprains of a major joint

23. Serious Injuries • Displaced long bone fractures • Multiple hand and foot fractures • Open long bone fractures • Displaced pelvic fractures • Dislocations of major joints • Multiple digit amputations • Laceration of major nerves or blood vessels

24. Severe Life-Threatening Injuries (Survival Is Probable) • Multiple closed fractures • Limb amputations • Fractures of both long bones on the leg (bilateral femur fractures)

25. Critical Injuries (Survival Is Uncertain) • Multiple open fracture of the limbs • Suspected pelvic fractures with hemodynamic instability

26. You are the Provider • You and your EMT-B partner are dispatched to the local skateboarding rink for a fall injury. • The scene is safe. • You find an 18-year-old male who is holding his left arm close to his chest. • He appears to be in a lot of pain. • He is conscious, alert, and oriented with no external bleeding.

27. You are the provider continued • What is the mechanism of injury? • What questions should you ask to determine the patient’s possible injury? • Should you stabilize the patient’s c-spine? • What could you do to ease the patient’s pain?

28. Scene Size-up • Carefully assess the MOI. • Observe for hazards and threats to safety; take BSI precautions. • Consider the need for spinal stabilization. • Evaluate the need for law enforcement. • Consider requesting ALS backup.

29. Initial Assessment (1 of 2) • Ask patient’s chief complaint; assess level of consciousness. • Ask about MOI. • Injuries to head may cause inadequate breathing. • You may administer oxygen to relieve anxiousness and improve perfusion. • Do not let the injury distract you from caring for ABCs.

30. Initial Assessment (2 of 2) • Treat patient for shock if signs of hypoperfusion are present. • Bandage bleeding extremities with sterile dressings to control bleeding • Do not make so tight as to restrict distal circulation. • Monitor bandage tightness by assessing circulation, sensation, and movement distal to injury. • Swelling may cause bandage to become too tight.

31. Transport Decision • Provide rapid transport if patient has airway or breathing problems. • If patient had significant MOI, transport rapidly even if patient seems okay. • Stabilize patient on a backboard.

32. You are the provider continued • You assess ABCs, take c-spine precautions, and provide oxygen via nonrebreathing mask. • Patient is a low-priority transport. • He tells you he fell while on a skateboard. He used his right arm to break the fall. • Heard a “pop” when he hit the concrete. Denies hitting his head or losing consciousness. • Right forearm is angulated slightly in the middle. He asks you not to touch it.

33. You are the provider continued • After your initial assessment, what should you do? • Describe the next phase of your assessment.

34. Focused History and Physical Exam • Use DCAP-BTLS. • Contusions, abrasions, or tenderness may be only signs of an underlying injury.

35. Rapid Physical Exam forSignificant Trauma • If you find no external signs of injury, ask patient to move each limb carefully, stopping immediately if this causes pain. • Skip this step if the patient reports neck or back pain. Slight movement could cause permanent damage to spinal cord.

36. Focused Physical Exam for Nonsignificant Trauma • Evaluate circulation, motor function, sensation. • If two or more extremities are injured, transport. • Severe injuries more likely if two or more bones have been broken • Recheck neurovascular function before and after splinting. • Impaired circulation can lead to death of the limb.

37. Assessing Neurovascular Status (1 of 4) • If anything causes pain, do not continue that portion of exam. • Pulse • Palpate the radial, posterior tibial, and dorsalis pedis pulses.

38. Assessing Neurovascular Status (2 of 4) • Capillary refill • Note and record skin color. • Press the tip of the fingernail to make the skin blanch. If normal color does not return within 2 seconds, you can assume that circulation is impaired.

39. Assessing Neurovascular Status (3 of 4) • Sensation • Check feeling on the flesh near the tip of the index finger. • In the foot, check the feeling on the flesh of the big toe and on the lateral side of the foot.

40. Assessing Neurovascular Status (4 of 4) • Motor function • Evaluate muscular activity when the injury is near the patient’s hand or foot. • Ask the patient to open and close his or her fist. • Ask the patient to wiggle his or her toes.

41. Baseline Vital Signs/SAMPLE History • Obtain baseline vital signs as soon as possible. • Shock is common. • Attempt to obtain SAMPLE history without delaying transport. • Extent of history depends on how quickly you need to transport.

42. Interventions • Stabilize ABCs. • Control serious bleeding. • Secure patient to a backboard if critically injured. • Provide prompt transport. • If patient is not critically injured, splint on scene. • Goal is to stabilize injury in most comfortable position that allows for maintenance of good circulation distal to site.

43. You are the provider continued (1 of 2) • You begin a focused physical exam. • You note tenderness, swelling, and crepitus with gentle palpation in the right mid-forearm. • Patient can feel you touch his fingers. Distal pulse is found. Capillary refill is normal. • Your partner manually stabilizes the injured extremity. You begin the SAMPLE history and assess vital signs.

44. You are the provider continued (2 of 2) • Describe your emergency care.

45. Detailed Physical Exam • Inspect and gently palpate other extremities and the spine to identify underlying fractures, dislocations, or sprains. • Compare injured limb to opposite, uninjured limb.

46. Ongoing Assessment • Repeat initial assessment and vital signs. • Reassess interventions. • Reassess neurovascular function and color of splinted injured extremity distal to injury site. • Communication and documentation • Report problems with ABCs, type of fracture, and if circulation was compromised before or after splinting. • Document complete descriptions of injuries and MOIs.

47. 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.

48. 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.

49. General Principles of Splinting (1 of 3) • Remove clothing from the area. • Note and record the patient’s neurovascular status. • Cover all wounds with a dry, sterile dressing. • Do not move the patient before splinting.

50. General Principles of Splinting (2 of 3) • Immobilize the joints above and below the injured joint. • Pad all rigid splints. • Apply cold packs if swelling is present. • Maintain manual immobilization. • Use constant, gentle, manual traction if needed. • If you find resistance to limb alignment, splint the limb as is.