1 Assessing and Treating Musculoskeletal Injuries May 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared by: Sharon Hopkins, RN,

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Assessing and Treating Assessing and Treating Musculoskeletal InjuriesMusculoskeletal Injuries

May 2012 CEMay 2012 CECondell Medical Center Condell Medical Center

EMS SystemEMS SystemSite Code: 107200E -1212Site Code: 107200E -1212

Prepared by: Sharon Hopkins, RN, BSN, EMT-PPrepared by: Sharon Hopkins, RN, BSN, EMT-PRev 6/14/12Rev 6/14/12

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ObjectivesObjectivesUpon 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.

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Objectives cont’dObjectives 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.

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Components - Musculoskeletal Components - Musculoskeletal SystemSystem

• 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)

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Function - Musculoskeletal SystemFunction - 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

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Bone MarrowBone Marrow

• Highly vascular

• Manufactures important blood components

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Musculoskeletal InjuriesMusculoskeletal Injuries

• Strain– Muscle injury from overstretching or

overexertion of the muscle

• Spain– Stretching or tearing of ligaments

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Musculoskeletal InjuriesMusculoskeletal 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

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Cascade of EventsCascade of Events

• Fracture occurs Destruction of blood vessels in periosteum &

bone and damage to surrounding vesselsSwelling of soft tissueFormation of a clot in the area Cell death at injury site due to disruption of blood

flowIntact surrounding cells divide & form a mass

around fracture siteNew bone is generated in weeks or months

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Assessment Musculoskeletal Assessment Musculoskeletal InjuriesInjuries

• “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?

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Signs & SymptomsSigns & 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

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Signs & Symptoms cont’dSigns & Symptoms cont’d

• Bruising- leaking of blood vessels

• Exposed bone ends– Open/comminuted fracture

Increases risk of infectionBone infection could lead to amputation

• Joints locked into place– Often seen with dislocations– Splint in position found

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Signs & Symptoms cont’dSigns & 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

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Assessment PEARLAssessment 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

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Care of the InjuryCare of the Injury

• Standard Precautions observed

• Perform baseline/initial assessmentPEARL

Musculoskeletal injuries are rarely ever life threatening

Could be life threatening for bilateral femur fractures and pelvic fracture

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Care of the Injury cont’dCare 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

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““RICE”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

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Guidelines for SplintingGuidelines 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

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DeformityDeformity

• 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

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When to Realign Deformed When to Realign Deformed ExtremitiesExtremities

• 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

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Realigning an InjuryRealigning 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

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Realigning an InjuryRealigning 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

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Splinting PEARLSSplinting 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

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Hazards of SplintingHazards 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

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Potentially Fatal Orthopedic InjuriesPotentially 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

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Stages of ShockStages 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

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Femur FractureFemur Fracture

• Presentation– Extreme pain

• A lot of muscle tissue surrounding the femur– Deformity– Swelling

• Treatment– Traction splint

• Best for mid shaft fractures

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Traction SplintingTraction 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

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Potentially Fatal InjuryPotentially 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

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Pelvic FracturesPelvic 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

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Pelvic FracturePelvic 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

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Compartment SyndromeCompartment 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

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Compartments of the LegCompartments of the Leg

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Compartment Syndrome cont’dCompartment 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

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Compartment SyndromeCompartment 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

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Signs and Symptoms Compartment Signs and Symptoms Compartment SyndromeSyndrome

• Early– Pain out of proportion to injury– Paresthesia – pins & needles sensation

• Late – 5 P’s– Pain– Pallor– Pulselessness– Paresthesia– Paralysis

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Compartment SyndromeCompartment Syndrome• Surgical intervention – fasciotomy

• Will need to return to OR for closure at a later date

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Compartment SyndromeCompartment 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

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Crush SyndromeCrush 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

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Crush Syndrome cont’dCrush 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

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Hyperkalemia – High PotassiumHyperkalemia – 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

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Types of SplintsTypes of Splints

• Rigid material

• Air splint

• Vacuum splint

• Slings

• HARE/Sager traction splint

• Back board

• Pillows

4343

Cervical Collar PEARLSCervical 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

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KED PEARLSKED 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

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HARE or Sager Traction PEARLSHARE 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

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Standing BackboardStanding 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

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Standing BackboardStanding 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

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DocumentationDocumentation

• 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?

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Documentation cont’dDocumentation 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

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Documentation cont’dDocumentation cont’d

– Consider the 6 P’s of extremity assessmentPainPallorParalysisParesthesiaPressurePulses

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Case Scenario DiscussionCase Scenario Discussion

• Review the following cases

• Follow the printed questions to prompt discussion

• Consider creative alternative to care for the wound when presented with unique challenges– There are not necessarily only one right

answer for each question posed

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Case Scenario #1Case Scenario #1• EMS called to a road construction crew

• Patient’s arm caught under a road compacting machine for a few minutes

• What safety issues need to be considered?– Traffic– Securing machine from movement– Exposure to blood and body fluids

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Case Scenario #1Case Scenario #1• How would you assess this wound?

• How would you care for this wound?

• How would you document this wound?

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Case Scenario #1Case Scenario #1

• Assess distal circulation, motion, and sensation status

• Can rinse gross debris away– Always use sterile normal saline on open wounds

• Avoid using sterile water on open wounds• Normal saline is isotonic; less destructive to damaged

tissue

• Cover open wound• Splint extremity in position of function

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• Documentation– Mechanism of injury (MOI)– Appearance of wound– Distal CMS/SMV/PMS before and after

splinting– Type of splinting/immobilization performed– Pain control measures– Response to interventions

5656


• EMS received a call to a local factory for a patient with their arm caught in machinery

• Upon arrival, you note the right forearm is caught in a machine

• What safety issues need to be considered?

5757


• How would you assess this wound?



5858

Case Scenario #2Case Scenario #2• What risks to the patient are associated

with crush injuries?– Release of toxins into the bloodstream once

the pressure is released especially after long entrapment

– Circulating potassium is a cardiac irritant• Watch for dysrhythmias via cardiac monitor

– By-products of myoglobinemia can decrease kidney function causing acute renal failure

• Provide IV fluids

5959


• EMS responded to the scene for a patient injured during a fall

• Upon arrival, you note an elderly female sitting on the ground supporting their left arm

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• How would you assess this wound?• Distal CMS/SMV/PMS before and after

splinting

• How would you care for this wound?– Splint in position found– May need to pad splint material– Apply ice over splinting material– Elevate arm

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• What else do you need to think about in caring for this patient?– WHY DID THE PATIENT FALL???

• Remember: Unless it is a clumsy tripping, consider a cardiac/stroke issue until proven otherwise

– Obtain EKG rhythm strip– Perform Cincinnati Stroke Scale

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• What do you think about this documentation?– Upon arrival found patient sitting on the ground

supporting arm– Site evaluated– Pain 9/10; 7/10– Above vital signs obtained– Patient placed on backboard and in collar– Patient transported

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• Documentation issuesWhy did patient fall?What did you find on assessment of the injury?How did you splint the injury?What was the distal CMS/SMV/PMS before and

after splinting?What were the responses to interventions

applied?

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• Drug/solution area filled in:– O2 4l per nasal cannula

• What about pain control?– Patient could get Fentanyl

• Why is oxygen applied?– Remember criteria: SpO2 <94% and/or

respiratory complaints or compromise

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• EMS called for a 5 y/o pedestrian who fell exiting a bus and then was run over

• The scene is chaos– Congested with parents, neighbors, bus driver,

other children still on the bus

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For discussion

• What safety issues need to be considered?

• How do you exert crowd control?

• Describe patient assessment– What additional injuries may have occurred?– What trauma category is this patient?

• Describe treatment of wounds


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Case Scenario #4Case Scenario #4• Injury contained to left leg

– Bone deep laceration to left patella– Quadricep tendon cut through– Skin over anterior left leg avulsed – bone

exposed– Tendons in ankle exposed– Tendons over dorsum foot severed from

proximal insertion– Metatarsals exposed

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• How would you assess this wound?• After viewing the OR picture of the wound,

discuss how you would assess status of distal circulation



6969

Case Scenario #4 Hospital CourseCase Scenario #4 Hospital Course• Hypotensive and unstable on admission

– Amputation was anticipated• Debridement performed 5 days post injury• 13 days post injury external fixator applied;

removed in 15 days and replaced for another 7 days

• 25 days post injury skin grafting done• Multiple surgeries for removal fixator, casting,

cast removal• Outcome: limb shortened, foot drop present but

functional

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Case Scenario #4 OR RepairCase Scenario #4 OR Repair

• Fixator pins noted

• Donor site for skin grafting

• Mesh skin graft in place

7171


• Crush injury to hand

• What safety issues need to be considered at the site?– Is scene

safe?– Are BSI’s

in place?

7272


• How would you assess this wound?• How would you care for this wound?• Anything special in the care based on the

picture?– Any constricting material (ie: the ring) need to

be removed ASAP• Document what you did with personal

effects taken from the patient

• How would you describe this wound?

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Equipment PracticeEquipment Practice

• Form small groups

• Practice proper utilization of– Measurement and placement of cervical collar– Application of KED– Application of back board with “patient”

standing

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BibliographyBibliography

• Region X Advanced Life Support Standard Operating Procedures February 1, 2012

• Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices Third Edition. Brady. 2009.

• Campbell, J. International Trauma Life Support for Emergency Care Providers. 7th edition. Pearson. 2012.

• Limmer, D., O’Keefe, M. Emergency Care 12th Edition. Brady. 2012.

• emedicine.medscape/article/1007814-overview • lifeinthefastlane.com• modernmedicine.com

Documents

1 Assessing and Treating Musculoskeletal Injuries May 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared by: Sharon Hopkins, RN,