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Muscle Skeletal

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SSgt Jeffery C. Pintler …

SSgt Jeffery C. Pintler
Washington Air National Guard


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  • Great for military. I plan to use with 86th CSH for educating medics.
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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

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