Musculoskele

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Musculoskele

  1. 1. Musculoskeletal Trauma EMS Professions Temple College
  2. 2. Incidence/Mortality/Morbidity <ul><li>Occur in 70-80% of all multi-trauma patients </li></ul><ul><li>Blunt or Penetrating </li></ul><ul><li>Upper extremity rarely life-threatening </li></ul><ul><ul><li>may result in long-term impairment </li></ul></ul><ul><li>Lower extremity associated with more severe injuries </li></ul><ul><ul><li>possibility of significant blood loss </li></ul></ul><ul><ul><li>femur, pelvic injuries may pose life-threat </li></ul></ul>
  3. 3. Incidence/Mortality/Morbidity <ul><li>Problem is not just the bone injury </li></ul><ul><ul><li>Other injuries caused by the injured bone </li></ul></ul><ul><ul><ul><li>Soft tissue </li></ul></ul></ul><ul><ul><ul><li>Vascular </li></ul></ul></ul><ul><ul><ul><li>Nervous system </li></ul></ul></ul><ul><ul><ul><li>Decreased function </li></ul></ul></ul>
  4. 4. Prevention Strategies <ul><li>Sports Training </li></ul><ul><li>Seat Belt use </li></ul><ul><li>Child Safety Seat use </li></ul><ul><li>Airbag use </li></ul><ul><li>Gun Safety and Education </li></ul><ul><li>Motorcycle education and protective equipment </li></ul><ul><li>Fall prevention </li></ul><ul><li>Can you think of others? </li></ul>
  5. 5. Musculoskeletal System Function <ul><li>Scaffolding/Support </li></ul><ul><li>Protection of vital organs </li></ul><ul><li>Locomotion </li></ul><ul><li>Production of RBC </li></ul><ul><li>Storage of minerals </li></ul>
  6. 6. Musculoskeletal Structures <ul><li>Skin </li></ul><ul><li>Muscles </li></ul><ul><li>Bones </li></ul><ul><li>Tendons </li></ul><ul><li>Ligaments </li></ul><ul><li>Cartilage </li></ul>
  7. 7. Musculoskeletal Structures - Skin <ul><li>Holds all structures together </li></ul><ul><li>Barrier function </li></ul><ul><li>Protects underlying structures </li></ul><ul><li>Subcutaneous tissue </li></ul><ul><ul><li>Fat </li></ul></ul><ul><ul><li>Fascia </li></ul></ul><ul><li>Further discussion in Soft-Tissue Trauma </li></ul>
  8. 8. Musculoskeletal Structures - Muscle <ul><li>Composed of specialized cells with ability to contract </li></ul><ul><li>Voluntary (Skeletal) </li></ul><ul><ul><li>Conscious control </li></ul></ul><ul><ul><li>Allows mobility </li></ul></ul><ul><li>Smooth (Bronchi, GI tract, blood vessels) </li></ul><ul><ul><li>Controlled by ANS </li></ul></ul><ul><ul><li>Able to alter inner lumen diameter </li></ul></ul><ul><li>Cardiac </li></ul><ul><ul><li>Contracts rhythmically on its own </li></ul></ul>
  9. 9. Musculoskeletal Structures - Muscle <ul><li>Can only contract </li></ul><ul><li>Skeletal muscle causes movement by shortening resulting in pulling on bones through cord like bands </li></ul>
  10. 10. Musculoskeletal Structures <ul><li>Tendons </li></ul><ul><ul><li>Bands of connective tissue binding muscles to bones </li></ul></ul><ul><li>Cartilage </li></ul><ul><ul><li>Connective tissue covering the epiphysis </li></ul></ul><ul><ul><li>Surface for articulation </li></ul></ul><ul><li>Ligaments </li></ul><ul><ul><li>Connective tissue supporting joints </li></ul></ul><ul><ul><li>Attach bone ends to each other </li></ul></ul>
  11. 11. Bones <ul><li>Living tissue </li></ul><ul><li>Consists of cells which deposit calcium, phosphorus on protein matrix </li></ul><ul><li>Constantly remodels itself </li></ul><ul><li>Able to repair damage without formation of scar tissue </li></ul>
  12. 12. Bones <ul><li>Structural form for body </li></ul><ul><li>Protection </li></ul><ul><li>Point of attachment for tendons, ligaments, cartilage and muscles </li></ul><ul><li>Allows for movement </li></ul><ul><li>Storage of minerals </li></ul><ul><li>Produce red blood cells </li></ul>
  13. 13. Skeletal System Components <ul><li>Axial Skeleton </li></ul><ul><ul><li>forms the central axis of the body </li></ul></ul><ul><ul><li>includes skull, vertebral column, bony thorax </li></ul></ul><ul><li>Appendicular Skeleton </li></ul><ul><ul><li>limbs </li></ul></ul><ul><li>Pectoral girdle </li></ul><ul><ul><li>bones that attach the upper limbs to the axial skeleton </li></ul></ul><ul><li>Pelvic girdle </li></ul><ul><ul><li>paired bones of the pelvis that attach the lower limbs to the axial skeleton and sacrum </li></ul></ul>
  14. 14. Long Bone Anatomy <ul><li>Diaphysis </li></ul><ul><ul><li>Long, narrow shaft </li></ul></ul><ul><ul><li>Dense, compact bone </li></ul></ul><ul><li>Metaphysis </li></ul><ul><ul><li>Head of bone </li></ul></ul><ul><ul><li>Between epiphysis and diaphysis </li></ul></ul><ul><li>Medullary canal </li></ul><ul><ul><li>Contains marrow </li></ul></ul>
  15. 15. Long Bone Anatomy <ul><li>Periosteum </li></ul><ul><ul><li>Outer fibrous covering </li></ul></ul><ul><ul><li>Allows for increase in diameter </li></ul></ul><ul><ul><li>Vascular </li></ul></ul><ul><ul><li>Nerves </li></ul></ul><ul><li>Epiphysis </li></ul><ul><ul><li>Articulated, widened end </li></ul></ul><ul><ul><li>Allows bone to lengthen </li></ul></ul><ul><ul><li>Cancellous bone with red blood marrow </li></ul></ul><ul><ul><li>Weakest point in child’s bone </li></ul></ul>
  16. 16. Joints <ul><li>Points of articulation between bones </li></ul><ul><li>Fused/Fibrous </li></ul><ul><ul><li>Sutures </li></ul></ul><ul><ul><ul><li>Between bones of skull </li></ul></ul></ul><ul><li>Synovial </li></ul><ul><ul><li>Fluid filled chamber which lubricates articulated surfaces </li></ul></ul><ul><ul><li>Allow for movement </li></ul></ul><ul><ul><ul><li>gliding, flexion, extension, abduction, adduction, circumduction, rotation </li></ul></ul></ul>
  17. 17. Synovial Joints <ul><li>Ball/Socket </li></ul><ul><ul><li>Shoulder/Hip </li></ul></ul><ul><li>Hinge </li></ul><ul><ul><li>Elbow/Knees/Fingers/TMJ </li></ul></ul><ul><li>Pivot </li></ul><ul><ul><li>Between radius and ulna </li></ul></ul><ul><li>Gliding </li></ul><ul><ul><li>Bones of wrist </li></ul></ul>
  18. 18. Fracture <ul><li>Break in continuity of bone </li></ul><ul><li>Closed </li></ul><ul><ul><li>Overlying skin intact </li></ul></ul><ul><li>Open </li></ul><ul><ul><li>Wound extends from body surface to fracture site </li></ul></ul><ul><ul><li>Produced either by bones or object that caused Fx </li></ul></ul><ul><ul><li>Danger of infection </li></ul></ul><ul><ul><li>Bone end not necessarily visible </li></ul></ul>
  19. 19. Mechanism of Injury <ul><li>Direct </li></ul><ul><ul><li>Break occurs at point of impact </li></ul></ul><ul><li>Indirect </li></ul><ul><ul><li>Force is transmitted along bone </li></ul></ul><ul><ul><li>Injury occurs at some point distant to point of impact </li></ul></ul><ul><ul><li>Femur, hip, pelvic fracture due to knees hitting dash </li></ul></ul>
  20. 20. Mechanism of Injury <ul><li>Twisting </li></ul><ul><ul><li>Distal limb remains fixed </li></ul></ul><ul><ul><li>Proximal part rotates </li></ul></ul><ul><ul><li>Shearing, fracturing occur </li></ul></ul><ul><ul><li>Football. skiing accidents </li></ul></ul><ul><li>Avulsion </li></ul><ul><ul><li>Muscle and tendon unit with attached fragment of bone ripped off bone shaft </li></ul></ul>
  21. 21. Mechanism of Injury <ul><li>Stress </li></ul><ul><ul><li>Occur in feet secondary to prolonged running or walking </li></ul></ul><ul><li>Pathological </li></ul><ul><ul><li>Result of Fx with minimal force </li></ul></ul><ul><ul><li>Cancer, osteoporosis </li></ul></ul>
  22. 22. Fracture Descriptions <ul><li>Open vs Closed </li></ul><ul><li>X-Ray descriptions </li></ul><ul><ul><li>greenstick </li></ul></ul><ul><ul><li>oblique </li></ul></ul><ul><ul><li>transverse </li></ul></ul><ul><ul><li>comminuted </li></ul></ul><ul><ul><li>spiral </li></ul></ul><ul><ul><li>impacted </li></ul></ul><ul><ul><li>epiphyseal </li></ul></ul>
  23. 23. Fracture Types <ul><li>Transverse </li></ul><ul><ul><li>Cuts shaft at right angle to long axis </li></ul></ul><ul><ul><li>Often caused by direct injury </li></ul></ul><ul><li>Greenstick </li></ul><ul><ul><li>Pliable bone splinters on one side without complete break </li></ul></ul><ul><ul><li>Occurs in children </li></ul></ul>
  24. 24. Fracture Types <ul><li>Spiral </li></ul><ul><ul><li>Fx site coils through bone like spring </li></ul></ul><ul><ul><li>Occurs with torsion </li></ul></ul><ul><li>Oblique </li></ul><ul><ul><li>Occurs at angle to long axis of shaft </li></ul></ul><ul><li>Comminuted </li></ul><ul><ul><li>Bone broken into 3 or more pieces </li></ul></ul>
  25. 25. Fracture Type <ul><li>Impacted </li></ul><ul><ul><li>Bone ends jammed together </li></ul></ul><ul><ul><li>Occurs with compression </li></ul></ul><ul><ul><li>Frequently no loss of function </li></ul></ul>
  26. 26. Problems Associated with Musculoskeletal Injuries <ul><li>Hemorrhage </li></ul><ul><li>Interruption of Blood Supply </li></ul><ul><li>Disability </li></ul><ul><li>Instability </li></ul><ul><li>Soft Tissue injury </li></ul>
  27. 27. Complications associated with Fractures <ul><li>Hemorrhage </li></ul><ul><ul><li>Possible loss within first 2 hours </li></ul></ul><ul><ul><ul><li>Tib/Fib - 500 ml </li></ul></ul></ul><ul><ul><ul><li>Femur - 500 ml </li></ul></ul></ul><ul><ul><ul><li>Pelvis - 2000 ml </li></ul></ul></ul><ul><li>Interruption of Blood Supply </li></ul><ul><ul><li>Compression on artery </li></ul></ul><ul><ul><ul><li>decreased distal pulse </li></ul></ul></ul><ul><ul><li>Decreased venous return </li></ul></ul>
  28. 28. Complications associated with Fractures <ul><li>Disability </li></ul><ul><ul><li>Diminished sensory or motor function </li></ul></ul><ul><ul><ul><li>inadequate perfusion </li></ul></ul></ul><ul><ul><ul><li>direct nerve injury </li></ul></ul></ul><ul><li>Specific Injuries </li></ul><ul><ul><li>Dislocation </li></ul></ul><ul><ul><li>Amputation/Avulsion </li></ul></ul><ul><ul><li>Crush Injury (soft tissue trauma discussion) </li></ul></ul>
  29. 29. Sprains/Strains <ul><li>Sprain </li></ul><ul><ul><li>tearing of ligaments surrounding joint </li></ul></ul><ul><li>Strain </li></ul><ul><ul><li>overstretching of muscle or tendon </li></ul></ul>
  30. 30. Musculoskeletal Assessment <ul><li>The possibilities </li></ul><ul><ul><li>Life-threatening injuries or conditions, including life/limb threatening musculoskeletal trauma </li></ul></ul><ul><ul><li>Life/Limb threatening injuries and only simple musculoskeletal trauma </li></ul></ul><ul><ul><li>Life/Limb threatening musculoskeletal trauma and no other life/limb threatening injuries </li></ul></ul><ul><ul><li>Only isolated, non-life/limb threatening injuries </li></ul></ul>
  31. 31. Musculoskeletal Assessment <ul><li>Initial Assessment </li></ul><ul><ul><li>ABCDs </li></ul></ul><ul><ul><li>Life threats managed first </li></ul></ul><ul><ul><li>Don’t overlook life/limb threatening musculoskeletal trauma </li></ul></ul><ul><ul><li>Don’t be distracted by “gross” but non-life/limb threatening musculoskeletal injury </li></ul></ul>
  32. 32. 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
  33. 33. Musculoskeletal Assessment <ul><li>The six “P”s of musculoskeletal assessment </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><ul><li>on palpation </li></ul></ul></ul><ul><ul><ul><li>on movement </li></ul></ul></ul><ul><ul><ul><li>constant </li></ul></ul></ul><ul><ul><li>Pallor - pale skin or poor cap refill </li></ul></ul><ul><ul><li>Paresthesia - “pins and needles” sensation </li></ul></ul><ul><ul><li>Pulses - diminished or absent </li></ul></ul><ul><ul><li>Paralysis </li></ul></ul><ul><ul><li>Pressure </li></ul></ul>
  34. 34. Musculoskeletal Assessment <ul><li>Vascular injury should be suspected in all Fx’s/dislocations UPO </li></ul><ul><li>Evaluate with 5 P’s </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Pallor </li></ul></ul><ul><ul><li>Pulselessness </li></ul></ul><ul><ul><li>Paresthesias </li></ul></ul><ul><ul><li>Paralysis </li></ul></ul>
  35. 35. Musculoskeletal Assessment <ul><li>History of Present Injury </li></ul><ul><ul><li>Where is pain felt? </li></ul></ul><ul><ul><li>What occurred? What position was limb in? </li></ul></ul><ul><ul><li>Were deceleration forces involved? </li></ul></ul><ul><ul><li>Was there direct impact? </li></ul></ul><ul><ul><li>Has there ever been previous trauma or Fx? </li></ul></ul>
  36. 36. Musculoskeletal Assessment <ul><li>Palpation and Inspection </li></ul><ul><ul><li>Swelling/Ecchymosis </li></ul></ul><ul><ul><ul><li>Hemorrhage/Fluid at site of trauma </li></ul></ul></ul><ul><ul><li>Deformity/Shortening of limb </li></ul></ul><ul><ul><ul><li>Compare to other extremity if norm is questioned </li></ul></ul></ul><ul><ul><li>Guarding/Disability </li></ul></ul><ul><ul><ul><li>Presence of movement does not rule out fracture </li></ul></ul></ul>
  37. 37. Musculoskeletal Assessment <ul><li>Palpation and Inspection </li></ul><ul><ul><li>Tenderness </li></ul></ul><ul><ul><ul><li>Use two point fixation of limb with palpation with other hand. </li></ul></ul></ul><ul><ul><ul><li>Tenderness tends to localize over injury site. </li></ul></ul></ul><ul><ul><li>Crepitus </li></ul></ul><ul><ul><ul><li>Grating sensation </li></ul></ul></ul><ul><ul><ul><li>Produced by bones rubbing against each other. </li></ul></ul></ul><ul><ul><ul><li>Do not attempt to elicit. </li></ul></ul></ul>
  38. 38. Musculoskeletal Assessment <ul><li>Palpation and Inspection </li></ul><ul><ul><li>Exposed bones </li></ul></ul><ul><ul><ul><li>Fx can be open without exposed bones </li></ul></ul></ul><ul><ul><li>Principal danger is not to bones, but to underlying neurovascular structures around bone. </li></ul></ul>
  39. 39. Musculoskeletal Assessment <ul><li>Palpation and Inspection </li></ul><ul><ul><li>Distal to injury, assess: </li></ul></ul><ul><ul><ul><li>skin color </li></ul></ul></ul><ul><ul><ul><li>skin temperature </li></ul></ul></ul><ul><ul><ul><li>sensation </li></ul></ul></ul><ul><ul><ul><li>motor function </li></ul></ul></ul><ul><ul><li>If uncertain, compare extremities </li></ul></ul><ul><ul><li>When in doubt splint! </li></ul></ul>
  40. 40. Musculoskeletal Assessment <ul><li>Because orthopedic injuries have low priority in multiple systems trauma, all Fx’s may not be found in field </li></ul><ul><li>Long Board </li></ul><ul><ul><li>Splints every bone and joint </li></ul></ul><ul><ul><li>No loss of time </li></ul></ul><ul><ul><li>Focus on critical conditions </li></ul></ul>
  41. 41. 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
  42. 42. 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
  43. 43. Management - General <ul><li>Immobilization Objectives </li></ul><ul><ul><li>Prevent further damage to nerves/blood vessels </li></ul></ul><ul><ul><li>Decrease bleeding, edema </li></ul></ul><ul><ul><li>Avoid creating an open Fx </li></ul></ul><ul><ul><li>Decrease pain </li></ul></ul><ul><ul><li>Early immobilization of long bone fractures critical in preventing fat embolism </li></ul></ul>
  44. 44. Management - General <ul><li>Principles of Fracture Management </li></ul><ul><ul><li>Splint joint above, below </li></ul></ul><ul><ul><li>Splint bone ends </li></ul></ul><ul><ul><li>Loosely cover open fracture sites </li></ul></ul><ul><ul><li>Neurovascular assessment </li></ul></ul><ul><ul><ul><li>before and after splinting </li></ul></ul></ul><ul><ul><li>Gentle in-line traction of long bone </li></ul></ul><ul><ul><ul><li>maintain normal alignment if possible </li></ul></ul></ul><ul><ul><ul><li>reduction of angulated fracture site </li></ul></ul></ul>
  45. 45. Management - General <ul><li>Principles of Fracture Management (cont) </li></ul><ul><ul><li>Position of function </li></ul></ul><ul><ul><li>Pain management </li></ul></ul><ul><li>Body Splinting </li></ul><ul><ul><li>In urgent patient, entire body is stabilized by using a long board </li></ul></ul><ul><ul><li>Lower extremity fractures can be splinted as one to the long board </li></ul></ul>
  46. 46. Management - General <ul><li>Pain Management </li></ul><ul><ul><li>Avoid pain management until head/thoracic injury is ruled out </li></ul></ul><ul><ul><li>Appropriate for isolated musculoskeletal injuries (fracture/sprain/dislocation) </li></ul></ul><ul><ul><li>Underutilized </li></ul></ul><ul><ul><li>Morphine sulfate titrated to pain relief without compromising adequate BP and ventilations </li></ul></ul>
  47. 47. Management - Pediatric <ul><li>Green stick Fx may go unrecognized </li></ul><ul><li>Fx can occur in epiphyseal plate, early closure can prevent further growth of affected bone </li></ul><ul><li>If no explanation from patient or parents or injury does not follow mechanism, suspect child abuse. </li></ul>
  48. 48. 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
  49. 49. Dislocations <ul><li>Displacement of bone end from articulating surface at joint </li></ul><ul><li>Pain or pressure is most common symptom </li></ul><ul><li>Principal sign is deformity </li></ul><ul><li>May experience loss of motion of joint </li></ul>
  50. 50. Dislocations <ul><li>Nerves, blood vessels pass very close to bone. Pressure on these structures can occur </li></ul><ul><li>Checking distally essential </li></ul><ul><ul><li>Pulse presence </li></ul></ul><ul><ul><li>Pulse strength </li></ul></ul><ul><ul><li>Sensation </li></ul></ul>
  51. 51. Management - Dislocations <ul><li>Principles of fracture/dislocation management </li></ul><ul><ul><li>Usually splinted in position of injury </li></ul></ul><ul><ul><li>Neurovascular assessment before, after splinting </li></ul></ul><ul><ul><li>Attempt realignment of dislocations if </li></ul></ul><ul><ul><ul><li>distal circulation is impaired </li></ul></ul></ul><ul><ul><ul><li>long transport </li></ul></ul></ul><ul><ul><li>Discontinue realignment if pain increased significantly or resistance is encountered </li></ul></ul><ul><ul><li>Immobilize proximal. distal joints and bones </li></ul></ul><ul><ul><li>Analgesia, possible cold application </li></ul></ul>
  52. 52. Sprains <ul><li>Stretching. tearing of ligaments surrounding joint </li></ul><ul><li>Occur when joint is twisted beyond normal range of motion </li></ul><ul><li>Most common = Ankle </li></ul>
  53. 53. Sprain Management <ul><li>Characteristics </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Tenderness </li></ul></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Discoloration </li></ul></ul><ul><li>Typically does not manifest deformity </li></ul><ul><li>Ice, compression, elevation, immobilize </li></ul><ul><li>When in doubt, splint </li></ul><ul><li>Consider analgesia </li></ul>
  54. 54. Strains <ul><li>Tearing, stretching of musculotendonous unit. </li></ul><ul><li>Spasm, pain on active movement </li></ul><ul><li>Usually no deformity, swelling </li></ul><ul><li>Pain present on active movement </li></ul><ul><li>Avoid active movement, weight bearing </li></ul>
  55. 55. Minor Musculoskeletal Injury Management <ul><li>Cold/Heat application </li></ul><ul><ul><li>cold best if in first 48 hours to reduce swelling </li></ul></ul><ul><ul><li>heat best if after 48 hours to increase circulation </li></ul></ul><ul><ul><li>no direct application to soft tissue </li></ul></ul><ul><ul><ul><li>wrap in towel or gauze </li></ul></ul></ul>
  56. 56. Minor Musculoskeletal Injury Management <ul><li>Other care </li></ul><ul><ul><li>Is immobilization/splinting needed? </li></ul></ul><ul><ul><li>Is an X-ray needed? </li></ul></ul><ul><ul><li>Is there a need for MD follow? ED visit? </li></ul></ul><ul><ul><li>What type of transport is needed? </li></ul></ul>
  57. 57. Traumatic Amputation <ul><li>First priority - ABC’s </li></ul><ul><ul><li>Bleeding from stump usually not a problem </li></ul></ul><ul><li>Next priority is to save limb </li></ul>
  58. 58. Traumatic Amputation Management <ul><li>Control Bleeding </li></ul><ul><li>Elevate </li></ul><ul><li>Apply direct pressure to stump </li></ul><ul><li>Avoid tourniquet except as last resort </li></ul>
  59. 59. Traumatic Amputation - Limb Management <ul><li>Place in saline moist gauze </li></ul><ul><li>Place in plastic bag </li></ul><ul><li>Place bag on ice </li></ul><ul><li>Do not </li></ul><ul><ul><li>Warm amputated part </li></ul></ul><ul><ul><li>Place part in water </li></ul></ul><ul><ul><li>Place directly on ice </li></ul></ul><ul><ul><li>Use dry ice </li></ul></ul>
  60. 60. Upper Extremity Fx <ul><li>Proximal Humerus </li></ul><ul><ul><li>Usually from a fall on outstretched hand. </li></ul></ul><ul><ul><li>Manage with sling, swathe </li></ul></ul><ul><ul><li>Deltoid bulge often accentuated </li></ul></ul><ul><li>Shaft of Humerus </li></ul><ul><ul><li>Usually obvious due to deformity </li></ul></ul><ul><ul><li>Wrist drop may occur </li></ul></ul><ul><ul><li>Vascular compromise may be present </li></ul></ul>
  61. 61. Upper Extremity Fx <ul><li>Colles Fx (silver fork) </li></ul><ul><ul><li>Distal radius </li></ul></ul><ul><ul><li>Usually secondary to fall on outstretched hand </li></ul></ul><ul><ul><li>Common in children </li></ul></ul>
  62. 62. Shoulder Dislocation <ul><li>Realignment </li></ul><ul><ul><li>One attempt if neurovascular compromise </li></ul></ul><ul><ul><li>Do not attempt if associated with other severe injuries or spine injuries </li></ul></ul><ul><ul><li>Provide analgesia </li></ul></ul><ul><ul><li>Pull into anatomical position </li></ul></ul><ul><li>Splinting </li></ul><ul><ul><li>Be creative </li></ul></ul><ul><ul><li>Sling, swathe if possible </li></ul></ul><ul><ul><li>Cravats are our friends! </li></ul></ul>
  63. 63. Hip Dislocation <ul><li>Anterior </li></ul><ul><ul><li>Blow to abducted leg, external rotation of affected extremity </li></ul></ul><ul><li>Posterior </li></ul><ul><ul><li>Blow to flexed/Abducted knee </li></ul></ul><ul><ul><li>More severe than anterior dislocation </li></ul></ul><ul><ul><li>Associated with rupture of joint capsule, acetabular Fx, sciatic nerve injury </li></ul></ul>
  64. 64. Management - Hip Dislocation <ul><li>Realignment </li></ul><ul><ul><li>One attempt if severe neurovascular compromise </li></ul></ul><ul><ul><li>Do not attempt if associated with other severe injuries </li></ul></ul><ul><ul><li>Provide analgesia </li></ul></ul><ul><ul><li>Steady and slow pull along shaft of femur </li></ul></ul><ul><ul><li>If successful, “pops” into joint, sudden relief of pain, leg can easily return to extension </li></ul></ul><ul><li>Immobilization </li></ul><ul><ul><li>Flexion of hip/knee for comfort acceptable </li></ul></ul>
  65. 65. Pelvic Fracture <ul><li>Direct or indirect force </li></ul><ul><li>Pelvic ring tends to break in two places </li></ul><ul><li>Bone fragments can cause damage </li></ul><ul><ul><li>Major vessels </li></ul></ul><ul><ul><li>Urinary bladder </li></ul></ul><ul><ul><li>Rectum resulting in contamination </li></ul></ul><ul><ul><li>Nerves (Lumbrosacral plexus or sciatic) </li></ul></ul>
  66. 66. Pelvic Fx Management <ul><li>Treat as potential critical trauma patient </li></ul><ul><li>Comfortable position if possible </li></ul><ul><li>Splint = Minimize movement </li></ul><ul><ul><li>Scoop stretcher </li></ul></ul><ul><ul><li>Body to long board </li></ul></ul><ul><ul><li>MAST for splint </li></ul></ul><ul><li>Replace volume prn </li></ul><ul><ul><li>Possible 4000cc blood loss </li></ul></ul><ul><ul><li>2 IV of LR </li></ul></ul>
  67. 67. Femur Fx <ul><li>Femoral Neck (Hip) </li></ul><ul><ul><li>Most common in mid to late 60’s age group. </li></ul></ul><ul><ul><li>Leg tends to rotate outward </li></ul></ul><ul><ul><ul><li>looks like anterior hip dislocation </li></ul></ul></ul><ul><ul><li>Minimal blood loss tends to occur due to joint capsule </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>NO traction splint </li></ul></ul><ul><ul><li>long board, scoop or MAST </li></ul></ul>
  68. 68. Femur Fx <ul><li>Mid-Shaft </li></ul><ul><ul><li>Result from torsion in very young or old </li></ul></ul><ul><ul><li>High speed deceleration with impact </li></ul></ul><ul><ul><ul><li>Hypovolemic shock </li></ul></ul></ul><ul><ul><ul><li>Fat Embolism </li></ul></ul></ul><ul><ul><li>Early immobilization with traction splint will help prevent </li></ul></ul><ul><ul><li>1000 to 2000 cc blood loss </li></ul></ul>
  69. 69. Femur Fx - Management <ul><li>Assess for traction splint contraindications </li></ul><ul><li>May use PASG, secure to long board </li></ul><ul><ul><li>Secure to opposite extremity and then to long board (premise for the Sager splint) </li></ul></ul><ul><li>Assess for : </li></ul><ul><ul><li>Soft tissue, vascular, or nerve injury </li></ul></ul><ul><ul><li>Assess for hypovolemia </li></ul></ul>
  70. 70. Femur Fx - Management <ul><li>Traction Splints </li></ul><ul><ul><li>Used on mid-shaft femur fractures </li></ul></ul><ul><ul><li>Do not use if suspected fracture involves </li></ul></ul><ul><ul><ul><li>proximal or distal 1/3 of femur </li></ul></ul></ul><ul><ul><ul><li>pelvis </li></ul></ul></ul><ul><ul><ul><li>hip (or hip dislocation) </li></ul></ul></ul><ul><ul><ul><li>knee (or knee dislocation) </li></ul></ul></ul><ul><ul><ul><li>ankle (or ankle dislocation) </li></ul></ul></ul><ul><ul><li>What if time (patient instability) does not allow for traction splint application? </li></ul></ul>
  71. 71. Lower Extremity Fx <ul><li>Patellar </li></ul><ul><ul><li>Due to direct impact </li></ul></ul><ul><li>Tibia/Fibula </li></ul><ul><ul><li>High potential for: </li></ul></ul><ul><ul><ul><li>Open fracture </li></ul></ul></ul><ul><ul><ul><li>Hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Infection </li></ul></ul></ul><ul><li>Calcaneal </li></ul><ul><ul><li>Results from falls (foot landing) </li></ul></ul><ul><ul><li>High incidence of lumbar sacral compression </li></ul></ul>
  72. 72. Management - Lower Extremity Fx <ul><li>Patellar, Tibia/Fibula, and Calcaneal </li></ul><ul><ul><li>Assess for neurovascular impairment </li></ul></ul><ul><ul><li>Realign long bones </li></ul></ul><ul><ul><li>Splinting possibilities </li></ul></ul><ul><ul><ul><li>board splint or cardboard splint </li></ul></ul></ul><ul><ul><ul><li>vacuum splint </li></ul></ul></ul><ul><ul><ul><li>pillow </li></ul></ul></ul>
  73. 73. Elbow Dislocation <ul><li>Presentation </li></ul><ul><ul><li>High neurovascular traffic </li></ul></ul><ul><ul><li>Volkmann’s contracture - ischemia secondary to trauma causes ischemic contractions </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>assess for neurovascular impairment </li></ul></ul><ul><ul><li>sling </li></ul></ul><ul><ul><li>swathe </li></ul></ul><ul><ul><li>analgesia and position of comfort </li></ul></ul>
  74. 74. Knee Dislocation <ul><li>Presentation </li></ul><ul><ul><li>Trauma to popliteal artery </li></ul></ul><ul><ul><li>Many reduce spontaneously </li></ul></ul><ul><ul><li>Knee dislocation has a 50% incidence of associated vascular injury </li></ul></ul><ul><ul><li>Presence of distal pulse does not rule out vascular injury </li></ul></ul>
  75. 75. Management - Knee Dislocation <ul><li>Management </li></ul><ul><ul><li>Assess for neurovascular impairment </li></ul></ul><ul><ul><li>One attempt at realignment if impairment or delayed transport </li></ul></ul><ul><ul><li>Do not realign if associated with other severe injuries </li></ul></ul><ul><ul><li>analgesia and position of comfort </li></ul></ul><ul><ul><li>gentle, steady traction to move into normal position </li></ul></ul><ul><ul><ul><li>success by “pop” into joint, less deformity and pain, and increased mobility </li></ul></ul></ul>
  76. 76. Hemorrhage Management <ul><li>Direct Pressure </li></ul><ul><ul><li>Most effective method </li></ul></ul><ul><ul><li>Pressure bandage </li></ul></ul><ul><li>Elevation </li></ul><ul><ul><li>Combination with direct pressure </li></ul></ul><ul><li>Pressure Point </li></ul><ul><ul><li>Brachial, Femoral, Carotid </li></ul></ul><ul><li>Tourniquet </li></ul><ul><ul><li>last resort </li></ul></ul><ul><ul><li>rarely required </li></ul></ul>
  77. 77. Tourniquet <ul><li>Last resort, but do not wait too long. </li></ul><ul><li>Use flat wide material </li></ul><ul><li>BP cuff </li></ul><ul><li>Close to the wound as possible </li></ul><ul><li>Do not remove </li></ul><ul><li>Leave in plain view </li></ul><ul><li>Note time applied and clearly communicate during transfer of care </li></ul>

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