Alexander ch36 lecture

Copyright © 2017, 2012 Pearson Education, Inc. All Rights Reserved.
Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 36
Musculoskeletal
Injuries

• The Advanced EMT applies fundamental
knowledge to provide basic and selected
advanced emergency care and transportation
based on assessment findings for an acutely
injured patient.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Describe the structures and functions of the
musculoskeletal system, including bones, cartilage,
joints, ligaments, skeletal muscle, and tendons.
3. Give examples of direct, indirect, and twisting forces that
can produce musculoskeletal injuries.
4. Describe each of the following types of injuries:
dislocations and subluxations, fractures, sprains, and
strains.
5. Describe the signs and symptoms associated with injury
to the musculoskeletal system.
Objectives (1 of 4)

6. Explain why fractures of the femur, pelvis, and multiple
concomitant long bones are considered critical fractures.
7. Establish the priority for assessing and treating
musculoskeletal injuries with respect to a patient’s overall
condition.
8. Describe the rationale for assessing distal circulation,
sensation, and motor function before and after splinting a
musculoskeletal injury, and for frequently reassessing for
changes in distal neurovascular function.
9. Recognize signs and symptoms of compartment
syndrome.
Objectives (2 of 4)

10.Describe the pathophysiology of compartment
syndrome.
11.Consider the need for fluid replacement and pain
management in patients with musculoskeletal
injuries.
12.Explain the rationale for splinting musculoskeletal
injuries.
13.Describe special considerations for splinting pelvic
fractures.
14.Discuss pitfalls associated with improper splinting.
Objectives (3 of 4)

15.Compare and contrast the characteristics and uses of
various types of splints, including the following: formable
splints, improvised splints, pressure (air or pneumatic)
splints, rigid splints, sling and swathe, long backboard,
traction splints, and vacuum splints.
16.Given a variety of scenarios involving patients with
musculoskeletal injuries, manage the injuries using
general rules of proper splinting.
Objectives (4 of 4)

• Isolated musculoskeletal injuries are not life
threatening.
• Severe internal or external hemorrhage may
occur, resulting in life-threatening condition.
• Musculoskeletal injuries are part of multisystem
trauma.
• Do not be distracted from priorities of patient
assessment and care by dramatic-appearing
musculoskeletal injury.
Introduction (1 of 2)

• Identify problems with airway, breathing,
circulation.
• Recognize life-threatening musculoskeletal
injuries and mechanisms of injury.
• Focus on immobilizing injured extremity, or
splinting; manage immediate life threats; package
patient; transport.
• Back pain is common; can lead to temporary or
permanent disability.
Introduction (2 of 2)

Think About It
• What should Joey and Mark’s next immediate
steps entail?
• What questions should Joey and Mark ask at this
point?
• What are some potential injuries that could have
occurred?

Figure 36-1
The skeletal system.

Anatomy and Physiology Review (1 of 7)
• Musculoskeletal system consists of 206 bones
and more than 700 skeletal muscles.
– Provide shape to body
– Protect internal organs
– Provide for movement of body
– Produce red blood cells

Figure 36-2
Ligaments attach bone to bone.

Figure 36-3
Tendons connect muscle to bone.

• Skeletal muscles
– Voluntary movement, attachment to bones
– Muscle contracts, pulls attached bones together.
– Opposing muscles contract, move bones apart.

• Ligaments and tendons
– Ligaments
▪ Connective tissue, bone to bone
– Tendons
▪ Connective tissue, muscle to bone

• Cartilage
– Connective tissue found between two bones
– Provides shock absorption
– Allows bones to move against one another without
friction
– Provides structure without rigidity of bone

Figure 36-4
Bones of the upper extremities.

Figure 36-5
Bones of the lower extremities.

• Bones
– 206 bones comprise the skeletal system.
– Axial skeleton
▪ Head, bones of thorax, spine
– Appendicular skeleton
▪ Pelvis, shoulder girdles, bones of extremities
– Categorized by shape
▪ Long, short, flat, sesamoid

• Bones (continued)
– Living, metabolically active tissue with blood supply
and nerves
– Calcium and other minerals are deposited in bone and
released to blood as needed.
– Bone marrow in cavity of certain bones produces
blood cells.

• Joints
– Points at which bones meet and articulate to allow
motion
– Types of movement:
▪ Flexion, extension, adduction, abduction, circumduction,
rotation
– Complex structures of bone, cartilage, ligaments

Emergency Care (1 of 10)
• Consider mechanism of injury and chief complaint.
• Noncritical patient
– Properly assess and manage.
– Manage injury carefully.
• Critical patient
– Prepare for transport and manage ABCs.
– Use long backboard as single means of providing
immobilization for all musculoskeletal injuries.

• Focused assessment
– Use DCAP-BTLS mnemonic.
– Expose injured area.
– Use techniques of examination and palpation.
• What are some of the signs and symptoms of
musculoskeletal injuries?

• Focused assessment (continued)
– Neurovascular status of injured extremity
▪ Assess circulation.
▪ Assess tactile sensation by touching hand or foot distal to site
of injury.
▪ Assess motor function in upper extremities.

• Focused assessment (continued)
– Impaired distal neurovascular function due to
musculoskeletal trauma is limb-threatening injury;
transport without delay.
– Follow your realignment and analgesia protocol.
– Splint some injuries in the position found
– Assess neurovascular status before and after splinting
– Reassess periodically throughout transport

• Splinting and care of musculoskeletal injuries
– Immobilization decreases injury and pain.
– Elevate injured extremities.
– Apply cold pack to injured area.
– Splinting:
▪ Uses external device to stabilize injured extremity
▪ Prevents it from moving
– Splints come in many varieties; can be improvised.

• General principles of splinting; types of splints
– Treat life-threatening conditions first.
– Assess distal neurovascular status before and after
splinting.
– Pad splints.
– Immobilize injury to bone to include joint proximal to
injury and joint distal to injury.
– Immobilize injury to joint to include bone proximal to
injury and bone distal to injury.

• Rigid splints
– Wood, plastic, cardboard, or metal; require padding
– Secured in place with roller gauze; do not secure so
tightly that circulation compromised
• Moldable splints
– Similar to board splints; pliable in order to be molded to
fit extremity

Figure 36-6
Air splint applied to the lower leg.

• Pressure splints (air or pneumatic splints)
– Pliable material, such as vinyl
– Made like sleeve to be slipped onto extremity
– Double walled to create air chambers inflated after
splint applied
– May not allow access to reassess pulse

Figure 36-7
A vacuum splint immobilizing an injured arm.

• Vacuum splints
– Pliable material that conforms to shape of injured
extremity
– Air sucked out, and splint collapses upon itself and
becomes rigid

Figure 36-8
A sling and swathe applied to immobilize the shoulder and arm.

• Sling and swathe
– Standalone splint for shoulder or clavicle injury
– Adjunct to supporting splinted arm, elbow, forearm, or
hand
– Sling supports arm by suspending it from shoulder.
– Swathe is bandage or strap wrapped or tied around
patient’s torso.

Scan 36-1 (1 of 11)
Properly Applied Sling and Swathe
1. Prepare the sling by folding cloth into a triangle. A triangle bandage makes an
ideal arm sling.

Scan 36-1 (2 of 11)
2. Position the sling over the top of the patient’s chest as shown. Fold the patient’s injured
arm across his chest.

Scan 36-1 (3 of 11)
3. If the patient cannot hold his arm, have someone assist until you tie the sling.

Scan 36-1 (4 of 11)
4. Extend one point of the triangle beyond the elbow on the injured side. Take the bottom
point and bring it up over the patient’s arm. Then take it over the top of the injured shoulder.

Scan 36-1 (5 of 11)
5. If appropriate, draw up the ends of the sling so the patient’s hand is about 4 inches
above the elbow.

Scan 36-1 (6 of 11)
6. Tie the two ends of the sling together, making sure that the knot does not press against
the back of the patient’s neck. Pad with bulky dressings. (If spine injury is suspected, pin
the ends of the sling to the patient’s clothing. Do not tie around the neck.)

Scan 36-1 (7 of 11)
7. Check to be sure you have left the patient’s fingertips exposed. Then assess distal
neurovascular function. If the pulse is absent, take off the sling and repeat the procedure.
Then check again.

Scan 36-1 (8 of 11)
8. To form a pocket for the patient’s elbow, take hold of the point of material at the elbow
and fold it forward, pinning it to the front of the sling.

Scan 36-1 (9 of 11)
9. If you do not have a pin, twist the excess material and tie a knot in the point.

Scan 36-1 (10 of 11)
10. Form a swathe from a second piece of material. Tie it around the chest and the injured
arm, over the sling. Do not place it over the patient’s arm on the uninjured side.

Scan 36-1 (11 of 11)
11. Reassess distal neurovascular function. Treat for shock and provide high-concentration
oxygen. Take vital signs. Perform detailed assessments and reassessments as appropriate.

• Long backboard
– Patient-handling device
– Immobilize extremities of patient who is critical and
must be transported without delay.
– Move patient without complicating any extremity
injuries he may have.

Figure 36-9
Traction splint.

• Traction splint
– Applies traction to extremity
– Overcomes spasms of thigh muscles that
accompany femur fractures

General Assessment and Management
of Musculoskeletal Injuries (1 of 2)
• Traction splint
– Restores thigh muscles to normal length
▪ Decreases volume of space available to collect blood from
large blood vessels
▪ Aligns ends of femur, reducing pain
▪ Uses thigh muscles to provide stability
– Frame fits against fixed point of skeleton.
– Frame attached at second point used to apply traction
against fixed point.

General Assessment and Management
of Musculoskeletal Injuries (2 of 2)
• Traction splints (continued)
– Bipolar frame traction splint
▪ Two rails that comprise frame
– Unipolar traction splint frame
▪ Only one rail
– Formable splints
▪ Malleable material

Figure 36-10
A towel used as an improvised splint.

Emergency Care
• Improvised splints
– Any object or material used to immobilize injured
extremity.
– Be creative as long as you adhere to principles of
splinting.
– Examples: sticks, towel, cardboard box, pillow, rolled-
up magazine

Fractures
• Any break in bone
• Result from variety of forces:
– Direct
– Indirect
– Twisting

Table 36-1
Types of Forces That Can Cause Fractures
Type of Force Examples
Direct force Being struck by a baseball bat in the upper arm, resulting in a fracture to
the humerus
Indirect force Falling on outstretched hands, resulting in a fracture to the radius and
ulna
Twisting force Stepping into a hole while running, causing a twisting of the lower leg
and resulting in a fracture to the tibia and fibula

Fractures (2 of 7)
• Mechanisms
– Assaults, falls, gunshot wounds, motor vehicle crashes
(MVCs), substantial forces
• Pathologic fracture
– Bone breaks because it is weakened by disease.

Figure 36-11
Types of fractures.

Fractures (3 of 7)
• Types of fractures
– Comminuted
– Impacted
– Greenstick
– Oblique
– Spiral
– Transverse

Figure 36-12
Open and closed fractures.

Fractures (4 of 7)
• Types of fractures (continued)
– Open fracture
▪ Broken bone end causes break in integrity of skin
– Closed fracture
▪ Broken bone end does not break integrity of skin

Fractures (5 of 7)
• Complications of fractures
– Lacerate blood vessels and nerves
– Bleeding can be substantial and thus life threatening.
▪ Fractures of femur and pelvis; multiple long-bone fractures
– Injury to nerves by broken bone ends may result in
permanent loss of sensation, weakness, paralysis.

Fractures (6 of 7)
• Complications of fractures (continued)
– Five Ps of compartment syndrome
▪ Pain
▪ Paresthesia
▪ Pallor
▪ Paralysis
▪ Pulselessness

Fractures (7 of 7)
• Managing long-bone fractures
– Splint
▪ Rigid, moldable, pneumatic, vacuum
– Femur fractures often require traction splint.
– First, control bleeding from, and place dressings on,
any open wounds.
– Do not attempt to replace broken bone ends or
fragments back into wound.

Scan 36-2 (1 of 6)
Splinting a Long Bone
1. Apply manual stabilization to the injured extremity. Cover open wounds before applying
the splint.

Scan 36-2 (2 of 6)
2. Assess the distal neurovascular function.

Scan 36-2 (3 of 6)
3. If the deformity is severe, if distal pulses are absent, or if the distal extremity is cyanotic,
align with gentle manual traction.

Scan 36-2 (4 of 6)
4. Measure the splint for proper length.

Scan 36-2 (5 of 6)
5. Secure the entire injured extremity. Immobilize the hand (or foot) in the position
of function.

Scan 36-2 (6 of 6)
6. Reassess the distal neurovascular function.

Fractures (2 of 6)
• Managing long-bone fractures (continued)
– After immobolizing extremity with splint, elevate
extremity and apply cold pack.
– Reassess en route to hospital.
– Humerus and forearm:
▪ Splint with rigid, moldable, pneumatic, vacuum splint;
use sling and swathe to support and immobilize arm,
elbow, shoulder.

Fractures (3 of 6)
• Managing long-bone fractures (continued)
– Femur: if traction splint contraindicated
▪ Use rigid splint; be generous with padding.
– Lower leg
▪ Use rigid, moldable, pneumatic, vacuum splint; ensure
foot in neutral position.

Figure 36-13
(A)
(B)
Pelvic fractures can be splinted by (A) a PASG, or (B) a commercial pelvic splint.

Fractures (4 of 6)
• Critical fractures
– Femur, pelvis, scapula, first rib
– Scapula and first rib
▪ Force required to break bones can result in injury to
intrathoracic organs.
– Broken clavicle
▪ Can result in pneumothorax or laceration of large blood
vessels.
– Pelvic fracture
▪ Open-book fracture increases volume of pelvis; can result
in up to 2,000 mL of blood loss.

Fractures (5 of 6)
• Critical fractures (continued)
– Stabilizing the pelvis is essential.
– Commercial pelvic binders:
▪ Improvised pelvic binder (Kendrick Extrication Device [KED]);
PASG
– Single fractured femur can result in up to 1,500 mL of
blood loss.
– Bilateral femur fractures can result in loss of up to 50%
of blood volume.

Figure 36-14
(A)
(B)
Types of traction splints: (A) a bipolar traction splint; (B) a unipolar traction splint.

Fractures (6 of 6)
• Do not apply traction splint in following situations:
– Injury is within 2 inches from knee or hip
– Hip or pelvic injury suspected
– Injuries to knee, ankle, or lower leg

Scan 36-3 (1 of 6)
Applying a Unipolar Traction Splint
1. Assess distal neurovascular function. Place the splint along the medial aspect of the
injured leg. Adjust it so that it extends about 4 inches beyond the heel.

Scan 36-3 (2 of 6)
2. Secure the strap to the thigh.

Scan 36-3 (3 of 6)
3. Apply the ankle hitch and attach it to the splint.

Scan 36-3 (4 of 6)
4. Apply traction by extending the splint. Adjust the splint to 10 percent of the patient’s
body weight.

Scan 36-3 (5 of 6)
5. Apply the straps to secure the leg to the splint. Reassess distal neurovascular function.

Scan 36-3 (6 of 6)
6. Place the patient onto a long backboard for ease of patient movement. Strap the ankles
together, and secure the patient to the board.

Scan 36-4 (1 of 12)
Applying a Bipolar Traction Splint
1. Assess distal neurovascular function.

Scan 36-4 (2 of 12)
2. Stabilize the injured leg by applying manual traction.

Scan 36-4 (3 of 12)
3. Adjust the splint for proper length, using the uninjured leg as a guide.

Scan 36-4 (4 of 12)
4. Position the splint under the injured leg until the ischial pad rests against the bony
prominence of the buttocks. When the splint is in position, raise the heel stand.

Scan 36-4 (5 of 12)
5. Attach the ischial strap over the groin and thigh.

Scan 36-4 (6 of 12)
6. Make sure the ischial strap is snug but not tight enough to reduce distal circulation.

Scan 36-4 (7 of 12)
7. With the patient’s foot in an upright position, secure the ankle hitch.

Scan 36-4 (8 of 12)
8. Attach the S-hook to the D-ring and apply mechanical traction. Full traction is achieved
when the mechanical traction is equal to the manual traction, and the pain and muscle
spasms are reduced. In an unresponsive patient, adjust the traction until the injured leg is
the same length as the uninjured leg.

Scan 36-4 (9 of 12)
9. Fasten the leg support straps.

Scan 36-4 (10 of 12)
10. Reevaluate the ischial strap and ankle hitch to ensure that both are securely fastened.

Scan 36-4 (11 of 12)
11. Reassess distal neurovascular function.

Scan 36-4 (12 of 12)
12. Place the patient on a long backboard and secure with straps. Pad between the splint
and the uninjured leg. Secure the splint to the backboard.

Joint Injuries (1 of 3)
• Sprain
– Joint forced beyond normal range of motion (ROM),
stretching or tearing ligaments around joint
• Avulsion fracture
– Ligament tears away a piece of bone as it is stretched
and torn.

• Dislocation
– Complete displacement of a joint; produces obvious
deformity to affected joint
• Subluxation
– Partial displacement of a joint

• Hip fractures and dislocations
– Involve proximal femur
– Hip dislocations:
 Head of femur displaced to front or back of pelvis
– Occur from falls or forcing joint beyond normal range
of motion
– Hip injuries are extremely painful.
– Use scoop stretcher.

Muscle Injuries
• Strain
– Muscle fibers are stretched beyond their limitations,
resulting in tearing of fibers.
– Muscles are under extreme stress (lifting heavy
weight).
– Apply cold pack and immobilize the joint to prevent
movement.

Chapter Summary (1 of 3)
• Musculoskeletal injuries consist of group of
injuries involving bones and joints.
• Some injuries may be obvious and gruesome.
• Do not allow these injuries to distract you from
managing life-threatening injuries.
• When life-threatening injuries not present, assess
and manage musculoskeletal injuries by splinting.

• Multitude of splints available; choose most
appropriate for particular injury.
• Purpose of splinting is to reduce pain and prevent
additional injury from occurring.
• When splinting injuries to bone, immobilize joints
above and below injury site.
• When splinting injuries to joints, immobilize bones
above and below injury.

• Splint injury appropriately; failure to do so may
lead to further injury.
• Assess distal neurovascular status before and
after splinting.
• Document your findings.

Alexander ch36 lecture

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