Assessing and Treating Musculoskeletal Injuries

1. Assessing and Treating Musculoskeletal Injuries May 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared by: Sharon Hopkins, RN, BSN, EMT-P Rev 6/14/12

2. Objectives Upon successful completion of this module, the EMS provider will be able to: • 1. Discuss components and function of the muscular and skeletal systems. • 2. Predict injuries based on the mechanism of injury. • 3. Differentiate between fractures, dislocations, sprains, and strains. • 4. Describe the six P’s evaluated during a musculoskeletal assessment. • 5. Explain the general guidelines for splinting. • 6. Describe signs and symptoms of compartment syndrome.

3. Objectives cont’d • 7. Describe complications of compartment syndrome. • 8. Describe complications of crush syndrome. • 9. Demonstrate proper measurement and placement of a cervical collar. • 10. Demonstrate proper application of the KED. • 11. Demonstrate proper application of the HARE traction (or similar traction based on your department). • 12. Demonstrate standing take down with the back board. • 13. Successfully complete the post quiz with a score of 80% or better.

4. Components - Musculoskeletal System • Composed of: • Bones (dense connective tissue) • Joints (place where bones meet) • Muscles (tissues or fibers) • Skeletal (voluntary), smooth (involuntary), cardiac • Cartilage (connective tissue) • Tendons (bands of connective tissue) • Ligaments (connective tissue)

5. Function - Musculoskeletal System • Provide the framework of the body • Support and protect internal organs • Allow movement of body parts or organs • Storage of salts and minerals • Production site of red blood cells

6. Bone Marrow • Highly vascular • Manufactures important blood components

7. Musculoskeletal Injuries • Strain • Muscle injury from overstretching or overexertion of the muscle • Spain • Stretching or tearing of ligaments

8. Musculoskeletal Injuries • Dislocation • Disruption of a joint • Fracture • Any break in a bone • Simple = closed fracture • Compound = open fracture • Increased risk of contamination & infection • Most common bone injury

9. Cascade of Events • Fracture occurs         Destruction of blood vessels in periosteum & bone and damage to surrounding vessels • Swelling of soft tissue • Formation of a clot in the area • Cell death at injury site due to disruption of blood flow • Intact surrounding cells divide & form a mass around fracture site • New bone is generated in weeks or months

10. Assessment Musculoskeletal Injuries • “5 P’s” of evaluation • Pain or tenderness? • Pallor – paleness or poor capillary refill? • Paresthesia – pins and needles sensation? • Pulses – diminished or absent? • Paralysis – inability to move?

11. Signs & Symptoms • Pain and tenderness • Usually localized • Deformity • Compare for symmetry • Grating or crepitus • Increases pain levels • Swelling • From bleeding at the site • Remove watches, rings as soon as possible • Document what you did with the personal effects

12. Signs & Symptoms cont’d • Bruising- leaking of blood vessels • Exposed bone ends • Open/comminuted fracture • Increases risk of infection • Bone infection could lead to amputation • Joints locked into place • Often seen with dislocations • Splint in position found

13. Signs & Symptoms cont’d • Nerve & blood vessel compromise • Evaluate distal CMS/SMV/PMS • Evaluated before and after splinting DOCUMENT CMS/SMV/PMS!!! Document ALL assessment results

14. Assessment PEARL • During assessment, determine mechanism of injury • If patient fell, ask “WHY” • If fall related to tripping/losing balance, you are just dealing with the orthopedic injuries • If patient experienced dizziness, lightheadedness, wooziness, syncope, near-syncope… • Consider a cardiac event until proven otherwise • Consider need for EKG monitoring • Perform the Cincinnati Stroke Scale

15. Care of the Injury • Standard Precautions observed • Perform baseline/initial assessment PEARL Musculoskeletal injuries are rarely ever life threatening  Could be life threatening for bilateral femur fractures and pelvic fracture

16. Care of the Injury cont’d • Cover open wounds with sterile dressing • If life threatening situation, splint enroute if time • Note: Patients on backboard are essentially immobilized/splinted • If stable patient, can splint prior to transport

17. “RICE” • R – rest the injury (i.e.: splinting) • I – apply ice to wound • Never apply ice directly to the skin • Too damaging to the skin tissue and cells • C – apply compression to minimize swelling • Never pull tight on the ACE – will be too constrictive; let ACE unroll easily • E – elevate higher than the heart

18. Guidelines for Splinting • Must immobilize the joint above and joint below the injury • Minimizes movement which will decrease pain • Prevents additional soft tissue injury to nerves, arteries, veins, and muscle • Prevents a closed fracture from becoming an open fracture • Minimizes blood loss • Minimizes additional injuries to the site

19. Deformity • May make splinting difficult • Chance of compromise to nerves, arteries, and veins • Distal tissue may die due to compromised blood flow • May need to add extra padding • May need to be creative in choosing splinting material

20. When to Realign Deformed Extremities • Distal extremity cyanotic • Distal pulses cannot be palpated • When in doubt, call Medical control • For relatively short transport times, most injuries can and should be splinted in position found

21. Realigning an Injury • Goal: • Align joint to anatomical position • Splints applied in position of anatomical function • Position mimics a normal, relaxed pose for the extremity • Fingers slightly curved for hands

22. Realigning an Injury • General guidelines to follow if necessary: • 1 person grasps the distal extremity • 1 person places hands above & below injury • Apply gentle manual traction in the same direction as the long axis of the extremity • Stop if resistance is felt or bone ends may break thru the skin • Maintain gentle traction until splinting is accomplished

23. Splinting PEARLS • Can’t treat what you can’t see • Expose all injuries • Assess and document distal CMS/SMV/PMS before and after splinting • Consider need for padding around bony areas • If bone is protruding, do not push it back in • Cover with sterile gauze

24. Hazards of Splinting • Caring for extremity injuries prior to caring for life threatening injuries • Inappropriately staying on the scene to care for injured extremities prior to initiating transport • Improper or inadequate splinting • Too tight –circulation compromised • Too loose –movement allowed further injury

25. Potentially Fatal Orthopedic Injuries • Bilateral femur fracture • Typically results from excessive force • Consider the presence of additional injuries • Blood loss most likely with mid-shaft fractures • Can lose up to 2 units of blood (1000 ml) per femur fracture

26. Stages of Shock • Based on amount of blood loss • Stage 1 – up to 15% circulation volume • Average 500 – 750* ml (typical donation during blood drive) • Stage 2 – up to 15-25% circulation volume • Average 750 – 1250* ml • Stage 3 – up to 25-35% circulation volume • Average 1250 – 1750* ml • Stage 4 – up to >35% circulation volume *Averages calculated for a 70 kg person

27. Femur Fracture • Presentation • Extreme pain • A lot of muscle tissue surrounding the femur • Deformity • Swelling • Treatment • Traction splint • Best for mid shaft fractures

28. Traction Splinting • Relieves muscle spasm therefore reducing pain • Avoid if serious knee, tibial, or foot injuries • Avoid if any joint injury to hip or knee is suspected • Anterior hip fracture may look like a femur fracture • Head of femur often protrudes in inguinal area

29. Potentially Fatal Injury • Pelvic fracture • Frequently associated with extremity fractures • Usually result from MVC and falls from heights • Have high index of suspicion based on mechanism of injury • Can suffer from significant blood loss • Bones have rich supply of blood • Typically venous bleeding from disruption of bone surface

30. Pelvic Fractures • The most significant pelvic injury is open-book pelvic fracture • Symphysis is torn apart • Anterior pelvis opened like a book • Both sacroiliac joints usually disrupted

31. Pelvic Fracture • Assessment • Instability or pain when applying gentle posterior pressure on iliac crests or symphysis pubis during assessment • DO NOT ROCK PELVIS!!! • Could displace the fracture or disturb a hematoma • Up to 40% of patients also have abdominal injuries

32. Compartment Syndrome • Fascia is a non-stretching tough membrane that surrounds muscles and other structures in extremities • Multiple closed spaces created called compartments • Bleeding and swelling from trauma may create increased tissue pressure in the confined space

33. Compartments of the Leg

34. Compartment Syndrome cont’d • Increased pressure in confined space • Decreased blood flow • Hypoxia • Possible muscle, nerve, vessel impairment • May lead to cell death and amputation • Typically presents hours after initial insult • Surgical intervention required to relieve the pressures in compartment

35. Compartment Syndrome • Can occur with a patient with a casted extremity • Injured area continues to swell first few days • Casted area constricted and does not allow expansion of the swelling • Compartments become compromised • Have high index of suspicion for patient presenting with a cast • Pain level higher than expected usually the tip off

36. Signs and Symptoms Compartment Syndrome • Early • Pain out of proportion to injury • Paresthesia – pins & needles sensation • Late – 5 P’s • Pain • Pallor • Pulselessness • Paresthesia • Paralysis

37. Compartment Syndrome • Surgical intervention – fasciotomy • Will need to return to OR for closure at a later date

38. Compartment Syndrome • Risks of late diagnosis and intervention • Gangrene leading to need for amputation • Ischemic contractures and therefore loss of function • Rhabdomyolysis and acute renal failure • Syndrome caused by skeletal muscle injury • Leakage of large quantities of toxic intracellular contents into plasma • Basically, sludge of muscle protein attempting to be filtered thru kidneys is causing kidney damage

39. Crush Syndrome • Pressure on extremities during prolonged entrapment can disrupt blood flow • Typically 4 hours or longer of entrapment • Anaerobic metabolism in tissues occurs • Toxins produced & released from crushed tissues, muscles, and cells • Myoglobin - a muscle protein • Potassium • Phosphorus • Lactic acid – from anaerobic metabolism • Uric acid – from protein breakdown

40. Crush Syndrome cont’d • Patient at risk of cardiac dysrhythmia and severe kidney damage from toxins • Place patient on cardiac monitor • Watch for peaked T wave • Indication of excess potassium in vascular space • Increase IV fluid rate to keep kidneys hydrated and flushed

41. Hyperkalemia – High Potassium • Note peaked T wave (this is NOT ST elevation!!!) • Excess extracellular potassium is an irritant to the heart • Watch for dysrhythmias and potential arrest

42. Types of Splints • Rigid material • Air splint • Vacuum splint • Slings • HARE/Sager traction splint • Back board • Pillows

43. Cervical Collar PEARLS • Measure accurately for best fit • Improper fit causes greater risk of harm than it does good • Measure bottom of chin to top of shoulder • Eyes must be focused straight ahead

44. KED PEARLS • Helpful only when rapid extrication is not required • Maintain manual spinal motion restriction until fully secured • Carefully place the leg/thigh straps especially in the male population

45. HARE or Sager Traction PEARLS • Traction maintained manually until device in place and foot traction applied • Patients often experience instant relief of pain (from muscle spasms) once traction in place

46. Standing Backboard • Takes 3 persons to be safely performed • If you really need spinal motion restriction, doesn't make sense to have patient walk to cot and then lay down

47. Standing Backboard PEARL • Apply straps to finish securing the patient AFTER the patient is supine on the board • The patient will be manually held in place while the backboard is being lowered

48. Documentation • Assessment of injury by interview • Onset – what were you doing at the time? • Provocation/palliation – what makes the pain worse/better? • Quality – in your words, describe the pain • Radiation – does the pain radiate? • Severity – on a scale of 0-10, rate your pain • Time – what time did this happen?

49. Documentation cont’d • Observation of appearance • Blood loss present? • Deformity present? • Bruising present? • Assessment by palpation (CMS/SMV/PMS) • Pulses • Distal compared to proximal • Ability to wiggle distal extremities • Ability to differentiate area touched

50. Documentation cont’d • Consider the 6 P’s of extremity assessment • Pain • Pallor • Paralysis • Paresthesia • Pressure • Pulses