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Musculoskeletal Trauma

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

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Musculoskeletal Trauma

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  1. Musculoskeletal Trauma EMS Professions Temple College

  2. 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

  3. Incidence/Mortality/Morbidity • Problem is not just the bone injury • Other injuries caused by the injured bone • Soft tissue • Vascular • Nervous system • Decreased function

  4. 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?

  5. Musculoskeletal System Function • Scaffolding/Support • Protection of vital organs • Locomotion • Production of RBC • Storage of minerals

  6. Musculoskeletal Structures • Skin • Muscles • Bones • Tendons • Ligaments • Cartilage

  7. Musculoskeletal Structures - Skin • Holds all structures together • Barrier function • Protects underlying structures • Subcutaneous tissue • Fat • Fascia • Further discussion in Soft-Tissue Trauma

  8. 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

  9. Musculoskeletal Structures -Muscle • Can only contract • Skeletal muscle causes movement by shortening resulting in pulling on bones through cord like bands

  10. 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

  11. 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

  12. 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

  13. 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

  14. Long Bone Anatomy • Diaphysis • Long, narrow shaft • Dense, compact bone • Metaphysis • Head of bone • Between epiphysis and diaphysis • Medullary canal • Contains marrow

  15. 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

  16. 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

  17. Synovial Joints • Ball/Socket • Shoulder/Hip • Hinge • Elbow/Knees/Fingers/TMJ • Pivot • Between radius and ulna • Gliding • Bones of wrist

  18. 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

  19. 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

  20. 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

  21. Mechanism of Injury • Stress • Occur in feet secondary to prolonged running or walking • Pathological • Result of Fx with minimal force • Cancer, osteoporosis

  22. Fracture Descriptions • Open vs Closed • X-Ray descriptions • greenstick • oblique • transverse • comminuted • spiral • impacted • epiphyseal

  23. 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

  24. 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

  25. Fracture Type • Impacted • Bone ends jammed together • Occurs with compression • Frequently no loss of function

  26. Problems Associated with Musculoskeletal Injuries • Hemorrhage • Interruption of Blood Supply • Disability • Instability • Soft Tissue injury

  27. 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

  28. 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)

  29. Sprains/Strains • Sprain • tearing of ligaments surrounding joint • Strain • overstretching of muscle or tendon

  30. 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

  31. Musculoskeletal Assessment • Initial Assessment • ABCDs • Life threats managed first • Don’t overlook life/limb threatening musculoskeletal trauma • Don’t be distracted by “gross” but non-life/limb threatening musculoskeletal injury

  32. 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

  33. 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

  34. Musculoskeletal Assessment • Vascular injury should be suspected in all Fx’s/dislocations UPO • Evaluate with 5 P’s • Pain • Pallor • Pulselessness • Paresthesias • Paralysis

  35. 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?

  36. 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

  37. 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.

  38. 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.

  39. Musculoskeletal Assessment • Palpation and Inspection • Distal to injury, assess: • skin color • skin temperature • sensation • motor function • If uncertain, compare extremities • When in doubt splint!

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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

  47. 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.

  48. 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

  49. 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

  50. Dislocations • Nerves, blood vessels pass very close to bone. Pressure on these structures can occur • Checking distally essential • Pulse presence • Pulse strength • Sensation

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