Ch07 musculoskeletal

Bledsoe et al., Paramedic Care: Principles & Practice, Volume 4: Trauma Emergencies, 3rd. Ed.© 2009 by Pearson Education, Inc. Upper Saddle River, NJ

Paramedic Care:Principles & Practice

Volume 5Trauma Emergencies


Topics

Introduction to Musculoskeletal TraumaAnatomy and Physiology of the Musculoskeletal SystemPathophysiology of the Musculoskeletal SystemMusculoskeletal Injury AssessmentMusculoskeletal Injury Management


Introduction to Musculoskeletal Injuries


Introduction to Musculoskeletal Injuries

In trauma, incidences of musculoskeletal injury are second in frequency only to soft-tissue injuries. – Millions of Americans sustain musculoskeletal

injuries each year. – Multiple MOI

Falls, crashes, violence, etc.Multi-system trauma


Prevention StrategiesApplication of modern vehicle and highway designs and safe driving practices – Use of restraints

Workplace safety standardsSports activities remain a significant cause of injury – Protective gear, improved equipment design, and

better conditioning of athletes has reduced injuriesHousehold accidents and falls – Use of good safety practices


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



Bone Structure– Diaphysis– Epiphysis– Metaphysis

Growth plate– Medullary canal– Periosteum– Cartilage

Provides a smooth articulation surface for other bones



Bone Classification– Bones are classified according to their general

shape Long

Humerus, radius, ulna, tibia, fibula, metacarpals, metatarsals, and phalanges

ShortCarpals and tarsals

IrregularVertebrae, facial

FlatCranium, sternum, ribs, shoulder, and pelvis

SesamoidPatella



Joint Structure– Three basic types of joints

SynarthrosesImmovable joints

AmphiarthosesVery limited movement

DiarthrosesSynovial jointsPermit free movement



Diarthroses – Monaxial

jointsHinge jointsPivot joints

– Biaxial jointsCondyloid Ellipsoidal Saddle joints

– Triaxial jointsBall-and-socket



Ligaments– Bands of connective

tissue that hold bones together at joints

Joint Capsule– Synovial capsule– Synovial fluid– Bursae



Skeletal Organization– 206 bones– Axial skeleton

Head, thorax, and spine

– Appendicular skeleton

Upper extremitiesLower extremities


Bone Aging– Birth to adult (18–20)

Transition from flexible to firm bone– Adult to elderly (40+)

Reduction in collagen matrix and calcium saltsDiminution of bone strengthSpinal curvature




Types of Muscles– Smooth– Striated– Cardiac

Muscular Tissue and Structure– 600 muscle groups


Muscles



Skeletal muscles attach to the bones at a minimum of two locations – Origin– Insertion

Opposition– Allows straightening of

muscles

TendonsMuscle tone


Pathophysiology of the Musculoskeletal System


The complex arrangement of connective, skeletal, vascular, nervous, and muscular tissue is endangered whenever significant kinetic forces are applied to the extremities.



Muscular Injury– Results from direct blunt or penetrating trauma,

overexertion, or problems with oxygen supply during exertion

– Injuries include:Contusions Compartment syndromePenetrating injuriesFatigueCramps SpasmsStrains



Muscular Injury

Contusion– Small blood vessels rupture with crushing forces– Blood will pool beneath or within tissue layers

Compartment Syndrome– Occurs in extremities– Contained by the fascia, this swelling increases

the pressure within the compartment – Deep and burning pain that appears out of

proportion to the apparent injury


Muscular Injury

Penetrating injury– Deep lacerations may penetrate skin and

subcutaneous tissues Affects muscles belowContraction of the opposing muscle

Fatigue– Muscles reach their limit of performance – Cells become hypoxic– Strength diminishes


Muscular Injury

Muscle Cramping– A painful spasm of the muscle tissue – Due to accumulation of wastes

Electrolyte imbalances Lactic acid

Muscle Spasms– An intermittent (clonic) or continuous (tonic)

contraction– Spasm usually subsides with rest


Muscular Injury

Strain– Occurs when muscle fibers are overstretched by

forces that exceed the strength of the fibers Tearing of muscle occurs

– Fibers are damaged without internal bleeding, edema, or discoloration



Joint Injury– Sprain– Subluxation– Dislocation


Joint Injury

Sprain– Tearing of a joint capsule’s connective tissues

Ligaments– Classified according to degree of tear

Subluxation– A partial displacement of a bone end from its

position within a joint capsule – Differs from the sprain in that it more significantly

reduces the joint’s integrity


Joint Injury

Dislocation– A complete

displacement of bone ends from their normal joint position

– Danger of entrapping, compressing, or tearing blood vessels and nerves



Bone Injury– Caused by extreme

compressional forces or significant lateral forces

Exceeds the tensile strength of a bone

May be open or closed

© Mark C. Ide


Fractures

Types of Fractures– Hairline fracture– Impacted fracture– Transverse– Oblique– Comminuted– Spiral– Fatigue



Pediatric Considerations– Flexible nature

Greenstick fracture– Epiphyseal fracture

Geriatric Considerations– Osteoporosis

Pathological Fractures– Pathological diseases



General Considerations with Musculoskeletal Injuries– Neurological compromise– Decreased stability– Muscle spasm

Bone Repair Cycle– Osteocytes produce osteoblasts– Deposition of salts– Increasing strength of matrix



Inflammatory and Degenerative Conditions– Bursitis– Tendinitis– Arthritis

OsteoarthritisDegenerative

Rheumatoid arthritisChronic, systemic, progressive, debilitating

GoutInflammation of joints produced by accumulation of uric acid crystals


Musculoskeletal Injury Assessment


Musculoskeletal Injury Assessment

A patient with an isolated musculoskeletal injury will receive complete assessment and management at the scene. Look for indications of the severity of the trauma forces and the possibility that the forces also caused internal injuries.


Assessment

Scene Size-up– Don the appropriate personal protective

equipment – Clues to specific injuries

MOI– History may suggest other injuries


Assessment

Initial Assessment– Categories of urgency

Life- and limb-threatening injuryLife-threatening injury and minor musculoskeletal injuryNon-life-threatening injuries but serious musculoskeletal injuriesNon-life-threatening injuries and only isolated minor musculoskeletal injuries


Assessment

Rapid Trauma Assessment– Performed on any patient with any sign, symptom,

or mechanism of injury that suggests serious injury

– Perform in a carefully ordered way Pay attention to pelvis and femur areas

May be significant blood loss


Assessment

Focused History and Physical Exam– Observe and inquire carefully for signs and

symptoms of fracture, dislocation, or other musculoskeletal injury in each limb with suspected injury

– 6 Ps: Pain, Pallor, Paralysis, Paresthesia, Pressure, Pulses

– Carefully evaluate the distal circulation, sensation, and motor function

– Identify all injuries, prioritize them, and establish the order of care for them


Assessment

Detailed Physical Exam– A search for the signs and symptoms of further

injury Head-to-toe

– Look specifically where you have not looked before and with enough care to identify any subtle indications of injury


Assessment

Ongoing Assessment– Focus

Serial measurement of the patient’s vital signs, level of consciousness, and the signs and symptoms of the major trauma affecting the patient

– Monitor distal sensation and pulses frequently


Assessment

Sports Injury Consideration– Assess the mechanism of injury – Determine whether there was a major kinetic force

involved – Downplaying of injuries– Specific and serious musculoskeletal injury

associated with sports is the sprainCommonly the knee


Musculoskeletal Injury Management



General Principles– Protecting open wounds– Positioning the limb

You should not attempt alignment of dislocations and serious injuries within 3 inches of a joint.

– Immobilizing the injury– Checking neurovascular function

Pulse, motor, sensation


ManagementSplinting Devices– Rigid splints– Formable splints

Vacuum splintsAir splints

– Soft splints– Traction splints– Other splinting aids

Cravats or Velcro splints


Management

Fracture Care– Carefully immobilize the limb in the position found

unless there is a significant circulatory or nervous deficit.

– Ensure distal pulses, sensation, and motor function.

– If you identify any neurovascular deficit, attempt to correct the problem by gentle repositioning.


Management

Joint Care– Assess for distal neurovascular function

If present, immobilize the joint in the position found If absent, consider moving the limb to reestablish it

Reduction

– Splint the limb in the position of function and transport


Management

Muscular and Connective Tissue Care– To manage muscle, tendon, and ligament injuries,

immobilize the region surrounding them – Provide gentle circumferential bandaging

Monitor distal circulation – Application of local cooling – Elevation and position of function


Care for Specific FracturesPelvis– Involves either the

iliac crest or the pelvic ring

Pelvic ring fractures are often serious, life-threatening events due to hemorrhage

– Pelvic sling devicePASG as a reserve device only

– Fluid resuscitation


Care for Specific FracturesFemur Fractures– High-force injury– High potential for

shock– Assessment

considerations– Traction splints

Do not use if suspected pelvic, knee, tibia, or foot injuries

– PASG


Care for Specific Fractures

Tibia-Fibula Fractures– Frequently open fractures– Cover bone ends with moist dressing– Depending on level of fracture, use:

Rigid splintAir splintPillow



ClavicleMost frequently fractured bone in the body

Has the potential to cause serious internal injury

Transmitted to 1st and 2nd ribBe alert for lung injuryImmobilize the affected limb in a sling and swathe against the chest



Humerus– Difficult to immobilize at its proximal end

Most effective technique for splinting this fracture is to apply a sling and swathe

Radius/Ulna– Most commonly, fracture occurs at the distal end

of ulnaDisplaces in volar direction (toward palm)Colles’ fracture

– Splint forearm fractures with a short, padded rigid splint


Care for Specific Joint Injuries

Hip– The hip may dislocate in two directions

AnteriorWith the foot turned outward and the head of the femur palpable in the inguinal area

PosteriorMost common Knee flexed and the foot rotated internally



Hip Dislocation Management – Splint in most comfortable position– Document sensation and pulse– Prompt transport– Be alert for associated knee injuries or fractures



Knee Fracture or Dislocation – Orthopedic

emergency– Frequently causes

vascular injury– Dislocation

associated with 50% rate of amputation of leg



Knee Fracture or Dislocation– 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



Foot or Hand Injury – Common industrial

injuries– Often disabling– Rarely life

threatening– Splint foot with

pillow– Splint hand in

position of function


Care for Specific Joint InjuriesShoulder Injuries– Most commonly involves the proximal humerus,

lateral scapula, and distal clavicle– Shoulder Dislocation

Anterior dislocations displace the humoral head forward Posterior dislocations rotate the arm internally

The elbow and forearm held away from the chest Use pillow with sling and swathe



Elbow Injury – Fracture or

dislocation may cause neurovascular injury

– Splint in position found

– Transport promptly



Wrist/Hand Injury– Noticeable deformity and significant pain reported

by the patient – Rigid Splint

Keep hand in “position of function”– Air Splint

May be hard to reassess circulation– Pillow



Finger – Forces may displace the phalanges from their

joints May occur between the phalanges May occur between the proximal phalanx and the metacarpal

– Use tongue depressor to splint– Malleable splints


Soft and Connective Tissue Injuries

Massive muscular contusions and hematomas may contribute to hypovolemia. Ligament and tendon injuries can endanger the future function of a limb. Treat these injuries as you would dislocations and immobilize the adjacent joints.


MedicationsNitrous Oxide– 50% O2:50% N2O– Non-explosive– Effects dissipate in 2–5

minutes– Easily diffused into air-

filled spaces in body– Dose

Inhaled and self administered

– Onset1–2 minutes

Diazepam– Benzodiazepine– Antianxiety– Analgesic– Dose

5–15 mg titrated– Onset

10–15 minutes– Duration

15–60 minutes– Counteragent

Flumazenil


MedicationsMorphine Sulfate– Opiate alkaloid– Reduces vascular volume and cardiac preload– Do not administer to hypovolemic patients– Dose:

2mg IVP slow– Counteragent:

Narcan


MedicationsMeperidine– Demerol– Narcotic analgesic– Dose

50–100 mg– Counteragent

Narcan


MedicationsSublimaze– Fentanyl– Synthetic opioid– Equivalent to morphine– Dose

25–50 mg SIVP followed by an additional 25 mg as needed

– OnsetLess than a minute

– Duration3–6 hours

– ConsiderationsIf given too rapidly, chest wall rigidity may ensue, leading to respiratory compromise



Other Injury Considerations– Pediatric musculoskeletal injury

Greenstick fractures and epiphyseal fractures – Athletic musculoskeletal injury

Injuries to the joints are common – Patient refusals and referral– Psychological support

Concerned attitude and a professional demeanor Communicating frequently and compassionately


Summary

Introduction to Musculoskeletal TraumaAnatomy and Physiology of the Musculoskeletal SystemPathophysiology of the Musculoskeletal SystemMusculoskeletal Injury AssessmentMusculoskeletal Injury Management



















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Ch07 musculoskeletal