Musculoskele

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
possibility of significant blood loss
femur, pelvic injuries may pose life-threat

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

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?

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

Musculoskeletal Structures
Skin
Muscles
Bones
Tendons
Ligaments
Cartilage

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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.

Exposed bones
Fx can be open without exposed bones
Principal danger is not to bones, but to underlying neurovascular structures around bone.

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 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 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 - 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 - 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’s Estimate blood loss at each Fx site Evaluation of neurovascular deficiencies in distal extremity Management Error

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

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

Management - Dislocations
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

Sprains
Stretching. tearing of ligaments surrounding joint
Occur when joint is twisted beyond normal range of motion
Most common = Ankle

Sprain Management
Characteristics
Pain
Tenderness
Swelling
Discoloration
Typically does not manifest deformity
Ice, compression, elevation, immobilize
When in doubt, splint
Consider analgesia

Strains
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 Injury 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 Injury 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 Amputation
First priority - ABC’s
Bleeding from stump usually not a problem
Next priority is to save limb

Traumatic Amputation Management
Control Bleeding
Elevate
Apply direct pressure to stump
Avoid tourniquet except as last resort

Traumatic Amputation - Limb 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 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 Fx
Colles Fx (silver fork)
Distal radius
Usually secondary to fall on outstretched hand
Common in children

Shoulder 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 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 Dislocation
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 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 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 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 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 - 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 - 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 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 Extremity Fx
Patellar, Tibia/Fibula, and Calcaneal
Assess for neurovascular impairment
Realign long bones
Splinting possibilities
board splint or cardboard splint
vacuum splint
pillow

Elbow 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 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 Dislocation
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 Management
Direct Pressure
Most effective method
Pressure bandage
Elevation
Combination with direct pressure
Pressure Point
Brachial, Femoral, Carotid
Tourniquet
last resort
rarely required

Tourniquet
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

Musculoskele

by hossamgebaly on Mar 06, 2010

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Musculoskele — Presentation Transcript