This document provides an overview of musculoskeletal trauma, including: 1) Musculoskeletal injuries occur in 70-80% of multi-trauma patients and can range from minor impairments to life-threatening injuries like pelvic or femur fractures. 2) A thorough musculoskeletal assessment involves evaluating the six P's (pain, pallor, paresthesia, pulses, paralysis, pressure) as well as inspection and palpation of injuries. 3) Initial management of musculoskeletal trauma focuses on immobilization, hemorrhage control, and splinting fractures to prevent further injury while stabilizing the patient for transport.

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