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Musculoskele
 

Musculoskele

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    Musculoskele Musculoskele Presentation Transcript

    • 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
    • Musculoskeletal Assessment
      • 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
    • Musculoskeletal Assessment
      • 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 Assessment
      • Vascular injury should be suspected in all Fx’s/dislocations UPO
      • Evaluate with 5 P’s
        • Pain
        • Pallor
        • Pulselessness
        • Paresthesias
        • Paralysis
    • Musculoskeletal Assessment
      • 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?
    • Musculoskeletal Assessment
      • 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
    • Musculoskeletal Assessment
      • 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.
    • Musculoskeletal Assessment
      • 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.
    • Musculoskeletal Assessment
      • Palpation and Inspection
        • Distal to injury, assess:
          • skin color
          • skin temperature
          • sensation
          • motor function
        • If uncertain, compare extremities
        • When in doubt splint!
    • Musculoskeletal Assessment
      • 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
    • Management - General
      • 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
    • Management - General
      • 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
    • Management - General
      • 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