Muscle Skeletal

Musculoskeletal Trauma SSgt Jeffery C. Pintler Washington Air National Guard

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

Musculoskeletal System Function
Scaffolding/Support
Protection of vital organs
Movement
Production of Red Blood Cells
Storage of minerals

Musculoskeletal Structures
Skin
Muscles
Bones
Tendons
Ligaments
Cartilage

Muscular System

Skeletal System

Musculoskeletal Structures - Skin
Holds all structures together
Barrier function
Protects underlying structures
Subcutaneous tissue

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

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

Types of 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

Common fractures

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

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)

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

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

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.

Distal to injury, assess:
skin color
skin temperature
sensation
motor function
If uncertain, compare extremities
When in doubt splint!

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

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

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
Long Board
Splints every bone and joint
No loss of time
Focus on critical conditions

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

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 musculo/tendonous unit.
Spasm, pain on active movement
Usually no deformity, swelling
Pain present on active movement
Avoid active movement, weight bearing

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

Tourniquet applied to an arm amputation

Tourniquet applied to a leg amputation

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

Sling and swathes applied to humerus fracture

Applying a cravat sling

Splint applied to a fractured elbow

Swathes applied to a fractured elbow

Splint applied to a fractured forearm

Sling and swath applied to a fractured forearm

Splint applied to a fractured wrist

Improvised jacket sling

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

Military Anti-Shock Trousers Pneumatic Anti-Shock Garment

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

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

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

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)

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

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

Splint applied to an upper leg fracture

Splint applied to a fractured knee

Uninjured leg used as a splint

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

Applying and securing a field dressing

Applying manual pressure

Pressure points for control of arterial bleeding

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

Application of a tourniquet to stop bleeding

References
Field Manual 8-230 U.S. Army 2003
Combat Lifesaver Instructor Manual U.S. Army 2003

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Muscle Skeletal

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