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SSgt Jeffery C. Pintler …

SSgt Jeffery C. Pintler
Washington Air National Guard

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  • 1. Musculoskeletal Trauma SSgt Jeffery C. Pintler Washington Air National Guard
  • 2. 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
  • 3. Incidence/Mortality/Morbidity
    • Problem is not just the bone injury
      • Other injuries caused by the injured bone
        • Soft tissue
        • Vascular
        • Nervous system
        • Decreased function
  • 4. Musculoskeletal System Function
    • Scaffolding/Support
    • Protection of vital organs
    • Movement
    • Production of Red Blood Cells
    • Storage of minerals
  • 5. Musculoskeletal Structures
    • Skin
    • Muscles
    • Bones
    • Tendons
    • Ligaments
    • Cartilage
  • 6. Muscular System
  • 7. Skeletal System
  • 8. Musculoskeletal Structures - Skin
    • Holds all structures together
    • Barrier function
    • Protects underlying structures
    • Subcutaneous tissue
  • 9. Musculoskeletal Structures - Muscle
    • Three types of muscle cells
    • Voluntary (Skeletal)
      • Conscious control
    • Smooth (Bronchi, GI tract, blood vessels)
      • Unconscious control
    • Cardiac
      • Contracts rhythmically on its own
  • 10. Musculoskeletal Structures
    • Tendons
      • Bands of connective tissue binding muscles to bones
    • Cartilage
      • Connective tissue covering the ends of bones
      • Needed for joint movement
    • Ligaments
      • Connective tissue supporting joints
      • Attach bone ends to each other
  • 11. Types of Joints
    • Ball/Socket
      • Shoulder/Hip
    • Hinge
      • Elbow/Knees/Fingers/TMJ
    • Pivot
      • Between radius and ulna
    • Gliding
      • Bones of wrist
  • 12. 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
  • 13. Common fractures
  • 14. Fracture Descriptions
    • Open vs Closed
    • X-Ray descriptions
      • greenstick
      • oblique
      • transverse
      • comminuted
      • spiral
      • impacted
      • epiphyseal
  • 15. 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
  • 16. 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)
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. 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.
  • 21. Musculoskeletal Assessment
    • Palpation and Inspection
      • Distal to injury, assess:
        • skin color
        • skin temperature
        • sensation
        • motor function
      • If uncertain, compare extremities
      • When in doubt splint!
  • 22. 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
  • 23. Management - General
    • Immobilization Objectives
      • Prevent further damage to nerves/blood vessels
      • Decrease bleeding, edema
      • Avoid creating an open Fracture
      • Decrease pain
      • Early immobilization of long bone fractures critical in preventing fat embolism
  • 24. 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
  • 25. 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
    • Long Board
      • Splints every bone and joint
      • No loss of time
      • Focus on critical conditions
  • 26. 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
  • 27. Dislocations
    • Nerves, blood vessels pass very close to bone. Pressure on these structures can occur
    • Checking distally essential
      • Pulse presence
      • Pulse strength
      • Sensation
  • 28. Sprains
    • Stretching. tearing of ligaments surrounding joint
    • Occur when joint is twisted beyond normal range of motion
    • Most common = Ankle
  • 29. Sprain Management
    • Characteristics
      • Pain
      • Tenderness
      • Swelling
      • Discoloration
    • Typically does not manifest deformity
    • Ice, compression, elevation, immobilize
    • When in doubt, splint
    • Consider analgesia
  • 30. Strains
    • Tearing, stretching of musculo/tendonous unit.
    • Spasm, pain on active movement
    • Usually no deformity, swelling
    • Pain present on active movement
    • Avoid active movement, weight bearing
  • 31. 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
  • 32. Tourniquet applied to an arm amputation
  • 33. Tourniquet applied to a leg amputation
  • 34. 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
  • 35. Sling and swathes applied to humerus fracture
  • 36. Applying a cravat sling
  • 37. Splint applied to a fractured elbow
  • 38. Swathes applied to a fractured elbow
  • 39. Splint applied to a fractured forearm
  • 40. Sling and swath applied to a fractured forearm
  • 41. Splint applied to a fractured wrist
  • 42. Improvised jacket sling
  • 43. 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)
  • 44. 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
  • 45. Military Anti-Shock Trousers Pneumatic Anti-Shock Garment
  • 46. Femur Fracture
    • 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
  • 47. Femur Fracture
    • 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
  • 48. Femur Fracture - 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
  • 49. Femur Fracture - 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)
  • 50. Lower Extremity Fracture
    • 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
  • 51. Management - Lower Extremity Fracture
    • Patellar, Tibia/Fibula, and Calcaneal
      • Assess for neurovascular impairment
      • Realign long bones
      • Splinting possibilities
        • board splint or cardboard splint
        • vacuum splint
        • pillow
  • 52. Splint applied to an upper leg fracture
  • 53. Splint applied to a fractured knee
  • 54. Uninjured leg used as a splint
  • 55. Hemorrhage Management
    • Direct Pressure
      • Most effective method
      • Pressure bandage
    • Elevation
      • Combination with direct pressure
    • Pressure Point
      • Brachial, Femoral, Carotid
    • Tourniquet
      • last resort
      • rarely required
  • 56. Applying and securing a field dressing
  • 57. Applying manual pressure
  • 58. Pressure points for control of arterial bleeding
  • 59. 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
  • 60. Application of a tourniquet to stop bleeding
  • 61. References
    • Field Manual 8-230 U.S. Army 2003
    • Combat Lifesaver Instructor Manual U.S. Army 2003