Musculoskeletal Trauma EMS Professions Temple College

Musculoskeletal Musculoskeletal TraumaTrauma

EMS ProfessionsTemple College

Incidence/Mortality/Incidence/Mortality/MorbidityMorbidity

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

Incidence/Mortality/Incidence/Mortality/MorbidityMorbidity

Problem is not just the bone injury– Other injuries caused by the injured

bone» Soft tissue» Vascular» Nervous system» Decreased function

Prevention StrategiesPrevention 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?

Musculoskeletal System Musculoskeletal System FunctionFunction

Scaffolding/SupportProtection of vital organsLocomotionProduction of RBCStorage of minerals

Musculoskeletal Musculoskeletal StructuresStructures

SkinMusclesBonesTendonsLigamentsCartilage

Musculoskeletal Musculoskeletal Structures - Structures - SkinSkin Holds all structures together

Barrier function Protects underlying structures Subcutaneous tissue

– Fat– Fascia

Further discussion in Soft-Tissue Trauma

Musculoskeletal Musculoskeletal Structures -Structures -MuscleMuscle 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

Musculoskeletal Musculoskeletal Structures -Structures -MuscleMuscle Can only contract

Skeletal muscle causes movement by shortening resulting in pulling on bones through cord like bands

Musculoskeletal Musculoskeletal StructuresStructures

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

BonesBones

Living tissue Consists of cells which deposit

calcium, phosphorus on protein matrix

Constantly remodels itselfAble to repair damage without

formation of scar tissue

BonesBones

Structural form for body Protection Point of attachment for tendons,

ligaments, cartilage and muscles Allows for movement Storage of minerals Produce red blood cells

Skeletal System Skeletal System ComponentsComponents

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

Long Bone AnatomyLong Bone Anatomy

Diaphysis– Long, narrow shaft– Dense, compact bone

Metaphysis– Head of bone– Between epiphysis and diaphysis

Medullary canal– Contains marrow

Long Bone AnatomyLong 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

JointsJoints

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

Synovial JointsSynovial Joints

Ball/Socket–Shoulder/Hip

Hinge–Elbow/Knees/Fingers/TMJ

Pivot–Between radius and ulna

Gliding–Bones of wrist

FractureFracture

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

Mechanism of InjuryMechanism 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


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


Stress– Occur in feet secondary to prolonged

running or walking Pathological

– Result of Fx with minimal force– Cancer, osteoporosis

Fracture DescriptionsFracture Descriptions

Open vs Closed X-Ray descriptions

– greenstick– oblique– transverse– comminuted– spiral– impacted– epiphyseal

Fracture TypesFracture 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

Fracture TypesFracture 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

Fracture TypeFracture Type

Impacted – Bone ends jammed together– Occurs with compression– Frequently no loss of function

Problems Associated with Problems Associated with Musculoskeletal InjuriesMusculoskeletal Injuries

Hemorrhage Interruption of Blood Supply Disability Instability Soft Tissue injury

Complications associated Complications associated with Fractureswith 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

Complications associated Complications associated with Fractureswith Fractures

Disability– Diminished sensory or motor function

» inadequate perfusion» direct nerve injury

Specific Injuries– Dislocation– Amputation/Avulsion– Crush Injury (soft tissue trauma

discussion)

Sprains/StrainsSprains/Strains

Sprain– tearing of ligaments surrounding joint

Strain– overstretching of muscle or tendon

Musculoskeletal Musculoskeletal AssessmentAssessment

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


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


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


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

Musculoskeletal Musculoskeletal Assessment Assessment

Vascular injury should be suspected in all Fx’s/dislocations UPO

Evaluate with 5 P’s– Pain– Pallor– Pulselessness– Paresthesias– Paralysis


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?


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


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.


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.


Palpation and Inspection– Distal to injury, assess:

» skin color » skin temperature» sensation» motor function

– If uncertain, compare extremities– When in doubt splint!


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

Key PointKey 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

Key PointKey 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

Management - GeneralManagement - 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


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


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


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

Management - PediatricManagement - 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.

Oversight of volume loss when evaluating pt with multiple

Fx’sEstimate blood loss at each Fx

site

Evaluation of neurovascular deficiencies in distal extremity

Management ErrorManagement Error

DislocationsDislocations

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

DislocationsDislocations

Nerves, blood vessels pass very close to bone. Pressure on these structures can occur

Checking distally essential– Pulse presence– Pulse strength– Sensation

Management - Management - DislocationsDislocations

Principles of fracture/dislocation management– Usually splinted in position of injury– Neurovascular assessment before, after

splinting– Attempt realignment of dislocations if

» distal circulation is impaired» long transport

– Discontinue realignment if pain increased significantly or resistance is encountered

– Immobilize proximal. distal joints and bones

– Analgesia, possible cold application

SprainsSprains

Stretching. tearing of ligaments surrounding joint

Occur when joint is twisted beyond normal range of motion

Most common = Ankle

Sprain ManagementSprain Management

Characteristics– Pain– Tenderness– Swelling– Discoloration

Typically does not manifest deformity Ice, compression, elevation,

immobilize When in doubt, splint Consider analgesia

StrainsStrains

Tearing, stretching of musculotendonous unit.

Spasm, pain on active movement Usually no deformity, swelling Pain present on active movement Avoid active movement, weight

bearing

Minor Musculoskeletal Minor Musculoskeletal Injury ManagementInjury Management

Cold/Heat application– cold best if in first 48 hours to reduce

swelling– heat best if after 48 hours to increase

circulation– no direct application to soft tissue

» wrap in towel or gauze

Minor Musculoskeletal Minor Musculoskeletal Injury ManagementInjury Management

Other care– Is immobilization/splinting needed?– Is an X-ray needed?– Is there a need for MD follow? ED

visit?– What type of transport is needed?

Traumatic AmputationTraumatic Amputation

First priority - ABC’s– Bleeding from stump usually not a

problem Next priority is to save limb

Traumatic Amputation Traumatic Amputation ManagementManagement

Control Bleeding Elevate Apply direct pressure to stump Avoid tourniquet except as last

resort

Traumatic Amputation - Traumatic Amputation - Limb ManagementLimb Management

Place in saline moist gauze Place in plastic bag Place bag on ice Do not

– Warm amputated part– Place part in water– Place directly on ice– Use dry ice

Upper Extremity FxUpper Extremity Fx

Proximal Humerus– Usually from a fall on outstretched

hand. – Manage with sling, swathe– Deltoid bulge often accentuated

Shaft of Humerus– Usually obvious due to deformity– Wrist drop may occur– Vascular compromise may be present

Upper Extremity FxUpper Extremity Fx

Colles Fx (silver fork)– Distal radius– Usually secondary to fall on

outstretched hand– Common in children

Shoulder DislocationShoulder Dislocation

Realignment– One attempt if neurovascular

compromise– Do not attempt if associated with

other severe injuries or spine injuries– Provide analgesia– Pull into anatomical position

Splinting– Be creative– Sling, swathe if possible– Cravats are our friends!

Hip DislocationHip Dislocation

Anterior– Blow to abducted leg, external

rotation of affected extremity Posterior

– Blow to flexed/Abducted knee– More severe than anterior dislocation– Associated with rupture of joint

capsule, acetabular Fx, sciatic nerve injury

Management - Hip Management - Hip DislocationDislocation Realignment

– One attempt if severe neurovascular compromise

– Do not attempt if associated with other severe injuries

– Provide analgesia– Steady and slow pull along shaft of femur– If successful, “pops” into joint, sudden

relief of pain, leg can easily return to extension

Immobilization– Flexion of hip/knee for comfort acceptable

Pelvic FracturePelvic Fracture

Direct or indirect force Pelvic ring tends to break in two

places Bone fragments can cause damage

– Major vessels– Urinary bladder– Rectum resulting in contamination– Nerves (Lumbrosacral plexus or sciatic)

Pelvic Fx ManagementPelvic Fx Management

Treat as potential critical trauma patient

Comfortable position if possible Splint = Minimize movement

– Scoop stretcher– Body to long board– MAST for splint

Replace volume prn– Possible 4000cc blood loss– 2 IV of LR

Femur FxFemur Fx

Femoral Neck (Hip)– Most common in mid to late 60’s age

group.– Leg tends to rotate outward

» looks like anterior hip dislocation

– Minimal blood loss tends to occur due to joint capsule

Management– NO traction splint– long board, scoop or MAST

Femur FxFemur Fx

Mid-Shaft– Result from torsion in very young or

old– High speed deceleration with impact

» Hypovolemic shock» Fat Embolism

– Early immobilization with traction splint will help prevent

– 1000 to 2000 cc blood loss

Femur Fx - ManagementFemur Fx - Management

Assess for traction splint contraindications

May use PASG, secure to long board– Secure to opposite extremity and then

to long board (premise for the Sager splint)

Assess for :– Soft tissue, vascular, or nerve injury– Assess for hypovolemia

Femur Fx - ManagementFemur Fx - Management

Traction Splints– Used on mid-shaft femur fractures– Do not use if suspected fracture

involves» proximal or distal 1/3 of femur» pelvis» hip (or hip dislocation)» knee (or knee dislocation)» ankle (or ankle dislocation)

– What if time (patient instability) does not allow for traction splint application?

Lower Extremity FxLower Extremity Fx

Patellar– Due to direct impact

Tibia/Fibula– High potential for:

» Open fracture» Hemorrhage» Infection

Calcaneal– Results from falls (foot landing)– High incidence of lumbar sacral

compression

Management - Lower Management - Lower Extremity FxExtremity Fx

Patellar, Tibia/Fibula, and Calcaneal– Assess for neurovascular impairment– Realign long bones– Splinting possibilities

» board splint or cardboard splint» vacuum splint» pillow

Elbow DislocationElbow Dislocation

Presentation– High neurovascular traffic– Volkmann’s contracture - ischemia

secondary to trauma causes ischemic contractions

Management– assess for neurovascular impairment– sling– swathe– analgesia and position of comfort

Knee DislocationKnee Dislocation

Presentation– Trauma to popliteal artery– Many reduce spontaneously– Knee dislocation has a 50% incidence

of associated vascular injury– Presence of distal pulse does not rule

out vascular injury

Management - Knee Management - Knee DislocationDislocation

Management– Assess for neurovascular impairment– One attempt at realignment if

impairment or delayed transport– Do not realign if associated with other

severe injuries– analgesia and position of comfort– gentle, steady traction to move into

normal position» success by “pop” into joint, less deformity

and pain, and increased mobility

Hemorrhage ManagementHemorrhage Management

Direct Pressure– Most effective method– Pressure bandage

Elevation– Combination with direct pressure

Pressure Point– Brachial, Femoral, Carotid

Tourniquet– last resort– rarely required

TourniquetTourniquet

Last resort, but do not wait too long.

Use flat wide material BP cuff Close to the wound as possible Do not remove Leave in plain view Note time applied and clearly

communicate during transfer of care

Documents

Musculoskeletal Trauma EMS Professions Temple College