2008 2nd musculoskeletal trauma als,ils,bls pp cme

8/13/2019 2008 2nd Musculoskeletal Trauma ALS,ILS,BLS PP CME

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Musculoskeletal Trauma

Will/Grundy EMS System Continuing Medical Education

2ndTrimester 2008 ALS/ILS/BLS


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Figure 6-26 A

Functions of Muscular SystemFunctions of Muscular System

Movement

Body support andmaintenance of

posture

Heat production


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Properties of MuscleProperties of Muscle

Contractility

Excitability Capacity of muscle fibers to respond when

stimulated by a nerve impulse

Extensibility (stretchability) Capacity of muscle fibers to stretch beyond their

relaxed length

Elasticity

Ability to return to their original length after

contraction or stretching


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Skeletal MuscleSkeletal Muscle

Under conscious control

Makes up about 40% of the total bodymass

Has two attachments

Origin - usually the more fixed and proximalattachment

Insertion - more movable and distalattachment

Contractions are rapid and forceful


5/129Ffigure 6-39

Cardiac MuscleCardiac Muscle

Myocardium

Forms middle layer ofheart

Innervated by

autonomic nervoussystem but contracts

spontaneously without

any nerve supply Contractions are

strong and rhythmic


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Smooth MuscleSmooth Muscle

Found in the walls of hollow organs

(e.g., urinary bladder and uterus) and inthe walls of tubes (e.g., respiratory,digestive, reproductive, urinary, and

circulatory systems) Innervated by the autonomic nervous

system, regulating size of lumen oftubular structures

Contractions are strong and slow


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TendonsTendons

Bands of connective tissue binding

muscles to bones Allow for power of movement across the

joints

Supplied by sensory fibers that extend

from muscle nerves


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BursaeBursae

Flattened, closed sacs of synovial fluid

Found where a tendon rubs against abone, ligament, or other tendon

Reduce friction and act as a shockabsorber

Prone to fill with fluid when infected or

injured


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CartilageCartilage

Connective tissue covering the

epiphysis Acts as surface for articulation

Allows for smooth movement at joints


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LigamentsLigaments

Connective tissue that crosses joints

and attaches bone to bone Stretch more easily than tendons

Allow for stable range of motion


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FasciaFascia

Dense fibrous connective tissue that

forms bands or sheets Covers muscles, blood vessels, and

nerves

Supports and anchors the organs to

nearby structures


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Figure 6-9

BonesBones

Form bodys supportingframework

Protect some internal organsfrom mechanical injury

Act as points of attachment for

tendons, carti lage, and ligaments Act as levers on which muscles

act to produce movementspermitted by joints

Serve as a reservoir for calciumand phosphorus

Contain and protect red bone

marrow


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Biomechanics Of Body MovementBiomechanics Of Body Movement

Every bone (except the hyoid bone)

connects to at least one other bone Three major classifications of joints

Fibrous joints

Cartilaginous joints

Synovial joints


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Figure 6-17 A

Fibrous JointsFibrous Joints

Consist of two bones united by fibrous

tissue that have little or no movement Sutures (seams between flat bones)


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Figure 6-18

Fibrous JointsFibrous Joints

Syndesmoses

Gomphoses


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Cartilaginous JointsCartilaginous Joints

Unite two bones by means of hyaline

cartilage (synchondroses) orfibrocartilage (symphyses)

Synchondroses

Symphysis


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Figure 6-19

Synovial JointsSynovial Joints

Contain synovial fluid

Allow movement between

articulating bones Account for most joints of

appendicular skeleton

Plane or gliding joints Saddle joints

Hinge joints

Pivot joints Ball-and-socket joints

Ellipsoid joints


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Skeletal SystemSkeletal System

Axial skeleton (80 bones)

Forms the central (longitudinal) axis of thebody, includes:

Skull (28)

Cranium (8) Face (14)

Ear bones (6)

Hyoid bone (1) Vertebral column (26)

Thoracic cage (25)


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Figure 6-9

Skeletal SystemSkeletal System

Appendicular skeleton (126 bones)

Pectoral girdle (4) Clavicle

Scapula

Upper limbs (60)

Pelvic girdle (2)

Lower limbs (60)


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Types of BonesTypes of Bones

Long bones

Short bones

Flat bones

Irregular bones


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Components of a Long BoneComponents of a Long Bone

Diaphysis

Medullary (or marrow) cavity

Periosteum

Epiphysis


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Bone Markings TerminologyBone Markings Terminology

Depressions and

openings

Foramen

Sinus

Fossa

Projections and

protrusions

Condyle

Crest

Epicondyle

Facet Head

Process

Spine

Tubercle

Tuberosity (trochanter)


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Pectoral (Shoulder) GirdlePectoral (Shoulder) Girdle

Serves to attach arm to axial skeleton of

thorax Place of attachment for muscles of arm

and chest

Each pectoral girdle has two bones -

clavicle and scapula


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Scapula (Shoulder Blade)Scapula (Shoulder Blade)

Triangular flat bone

Glenoid fossa (glenoid cavity) Arm socket

Depression that receives the head of the humerusto form the shoulder joint

Allows rotation of the arm at the shoulder

Spine of scapula - long, posterior process formuscle attachment

Acromion - lateral end of spine of scapula thatarticulates with clavicle


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Clavicle (Collarbone)Clavicle (Collarbone)

Most frequently broken bone in the body

Long, slender, S-shaped bone that lieshorizontally just beneath the skin

Acts as a brace that holds the upper

limbs away from the trunk Serves to transmit forces from the upper

limbs to the axial skeleton Provides attachment for certain muscles

of neck, thorax, back, and arm


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Figure 6-13

HumerusHumerus

Longest and largest bone

of the upper extremity

Shoulder joint is the most

commonly dislocated

large joint Bursae around the

shoulder form a

lubricating mechanismduring movement of

shoulder joint


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Radius and UlnaRadius and Ulna

Bones of forearm connected by a flexible

connective tissue

Articulate to form a pivot joint that, with the

pronator and supinator muscles, permits turning

the palm up (supination) and palm down

(pronation)

When the palm is up, the radius and ulna areparallel

When the palm is down, the two bones cross


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Figure 6-13

RadiusRadius

Bone on thumb side

of forearm when palmis facing forward

Shorter than and

lateral to the ulna


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Figure 6-13

UlnaUlna

Longer of the two

forearm bones Located on little

finger side of

forearm

Medial to radius


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CarpalsCarpals

Bones of the wrist (carpus)

Arranged in two rows of four bones Articulate with one another at gliding

joints that permit sliding and twisting

Carpal tunnel Formed by the concave anterior surface of

the carpal bones Contains flexor tendons of the fingers and

the median nerve


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MetacarpalsMetacarpals

Five metacarpal bones

Miniature long bones that make up the palmof the hand

Heads of the metacarpals form the

knuckles of the hand

Metacarpophalangeal (MCP) joint


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PhalangesPhalanges

Finger bones

Miniature long bones

Each finger has three bones, the proximal, middle,

and distal phalanges

Each thumb has only two phalanges, proximal and

distal

Joints

Interphalangeal joints Distal interphalangeal (DIP) joints

Proximal interphalangeal (PIP) joints


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Figure 6-14

Pelvic GirdlePelvic Girdle

Consists of the sacrum,

coccyx, and two hip

bones (os coxae or

innominate bones)

Each hip bone is

formed by fusion of an

ilium, ischium, andpubis on each side of

the pelvis


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Figure 6-14

Pelvic GirdlePelvic Girdle

Bears the weight of

the body Serves as a place of

attachment for the

legs

Protects organs in

pelvic cavity


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Figure 6-15

FemurFemur

Thigh bone

Longest, strongest,

and heaviest boneof the body

Hip joint

Head

Neck

Greater trochanter Lesser trochanter

Shaft


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PatellaPatella

Kneecap

Largest sesamoid bone of the body Embedded in tendon of quadriceps

femoris muscle

Articulates with the femur

Knee joint

Tibi


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Figure 6-15

TibiaTibia

Shin bone

Medial and more

superficial bone oflower leg

Articulates with femurat the knee

Weight-bearing bone ofthe lower leg

Shaft

Medial ankle bone

Fib l


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Figure 6-15

FibulaFibula

Slenderest bone of the

body, proportional to its

length Long bone on lateral side

of lower leg

Functions to increase theavailable area for muscle

attachments in the leg

Head Shaft

Lateral ankle bone

T lT l


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Figure 6-16 A

TarsalsTarsals

Seven tarsal bones formthe ankle

Calcaneus Heel bone

Largest and strongest bone

of foot Lies below the talus

Body weight is supported

primarily by calcaneus andtalus

Talus

Second largest bone of foot

M t t lM t t l


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Figure 6-16 A

MetatarsalsMetatarsals

Five long bones thatform the sole(plantar surface) ofthe foot

Distal ends ofmetatarsals form theball of the foot

Metatarsophalangealjoints

Ph lPh l


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Figure 6-16 A

PhalangesPhalanges

Toe bones

Toes contain 14phalanges

Great toe has two

phalanges (proximal

and distal)

Other four toes havethree phalanges each


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A A i t d Ch i BAge Associated Changes in Bones


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Age Associated Changes in BonesAge Associated Changes in Bones

Vertebral column gradually assumes an

arc shape Costal cartilages ossify, making the

thorax more rigid

Shallow breathing due to rigid thoracic

cage

Facial contours change

Fractures

Cl ifi i f M l k l l I j iCl ifi ti f M l k l t l I j i


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Classifications of Musculoskeletal InjuriesClassifications of Musculoskeletal Injuries

Injuries that result from application of

traumatic forces include:

Fractures

Sprains

Strains

Joint dislocations

Associated ComplicationsAssociated Complications


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Associated ComplicationsAssociated Complications

Hemorrhage

Instability Loss of tissue

Simple laceration and contamination Interruption of blood supply

Nerve damage Long-term disability

Musculoskeletal InjuriesMusculoskeletal Injuries


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Musculoskeletal InjuriesMusculoskeletal Injuries

Can result from:

Direct trauma Blunt force applied to an extremity

Indirect trauma

A vertical fall that produces a spinal fracturedistant from the site of impact

Pathologic conditions

Some forms of arthritis

Malignancy

FracturesFractures


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FracturesFractures

A break in the continuity of a bone or

cartilage

May be complete or incomplete,

depending on the line of fracture

through the bone

May be classified as open or closed,

depending on the integrity of the skinnear the fracture site

Classification of FracturesClassification of Fractures


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Classification of FracturesClassification of Fractures

Open

Closed

Comminuted

Greenstick

Spiral

Oblique

Transverse

Stress

Pathological

Epiphyseal


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SprainsSprains


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SprainsSprains

A partial tearing of a ligament caused bysudden twisting or stretching of a joint

beyond its normal range of motion

Two common areas for sprains are the

ankle and the knee Sprains are graded by severity

First-degree sprain

Second-degree sprain

Third-degree sprain

StrainsStrains


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StrainsStrains

An injury to the muscle or its tendon

from overexertion or overextension

Commonly occur in the back and arms

May be accompanied by significant loss

of function

Severe strains may cause an avulsion of

bone from the attachment site

Joint DislocationsJoint Dislocations


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Joint DislocationsJoint Dislocations

Occur when the normal articulating ends oftwo or more bones are displaced

Luxation - a complete dislocation Subluxation - an incomplete dislocation

Frequently dislocated joints

Suspect a joint dislocation when a joint isdeformed or does not move with normal rangeof motion

All dislocations can result in great damageand instability

BursitisBursitis


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BursitisBursitis

Inflammation of a bursa (a small, fluid-

filled sac that acts as a cushion at a

pressure point near joints)

Most important bursae are around the knee,

elbow, and shoulder

BursitisBursitis


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BursitisBursitis

Bursitis is usually the result of:

Pressure (e.g., prolonged kneeling on a

hard surface)

Friction

Slight injury to the membranes surroundingthe joint

Treatment generally consists of rest,ice, and analgesics

TendonitisTendonitis


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TendonitisTendonitis

Inflammation of a tendon, often caused by

injury

Symptoms include:

Pain

Tenderness Restricted movement of the muscle attached to the

affected tendon

Treatment usually includes: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Corticosteroid medications

ArthritisArthritis


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ArthritisArthritis

Inflammation of a joint

Characterized by pain, swelling, stiffness,

and redness

A joint disease (involving one or many

joints) that can occur from many causes

Varies in severity from a mild ache and

stiffness to severe pain and later jointdeformity

ArthritisArthritis


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ArthritisArthritis

Osteoarthritis (degenerative arthritis)

most common

Pain associated with this condition is

usually managed with anti-inflammatory

agents

Extremity TraumaExtremity Trauma


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Extremity TraumaExtremity Trauma

Common signs and symptoms

Pain on palpation or movement

Swelling, deformity

Crepitus

Decreased range of motion

False movement (unnatural movement of

an extremity) Decreased or absent sensory perception or

circulation distal to the injury

Musculoskeletal AssessmentMusculoskeletal Assessment


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Musculoskeletal Assessment

Can be divided into four classes of patients:

Patients with life/limb-threatening injuries or

conditions, including life/limb-threateningmusculoskeletal trauma

Patients with other life/limb-threatening injuries

and only simple musculoskeletal trauma Patients with no other life/limb-threatening injuries

and life/limb-threatening musculoskeletal trauma

Patients with only isolated, non-life/limb-threatening injuries

AssessmentAssessment


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Conduct the initial assessment to

determine if there are any life-

threatening conditions

Care for those conditions first

Never overlook musculoskeletal trauma

Never allow a non-critical

musculoskeletal injury to distract frompriorities of care

Six "P"s of Musculoskeletal AssessmentSix "P"s of Musculoskeletal Assessment


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S s o uscu os e e a ssess e

Pain

Pain on palpation (tenderness)

Pain on movement

Pallor - pale skin or poor capillary refill

Paresthesia - pins and needles sensation Pulses - diminished or absent

Paralysis - inability to move

Pressure



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Evaluate an extremitys neurovascular

status by assessing distal pulse, motor

function, and sensation (before and

after movement or splinting)

Inspect and palpate injured area forDCAP-BTLS



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Compare the injured extremity with the

opposite, uninjured extremity

If extremity trauma is suspected,

immobilize the injury by splinting

General Principles of SplintingGeneral Principles of Splinting


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p p gg

The goal of splinting is immobilization

of the injured body part

Immobilization by splinting:

Helps alleviate pain

Decreases tissue injury, bleeding, and

contamination in an open wound Simplifies and facilitates patient transport



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p p g

Splint joints above and below, and bone

ends

Immobilize open and closed fractures in

the same manner

Cover open fractures to reduce

contamination

Check pulses, sensation, and motorfunction before and after splinting



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Stabilize the extremity with gentle, in-

line traction to a position of normal

alignment

Immobilize a long bone extremity in a

straight position that can easily besplinted



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Immobilize dislocations in position ofcomfort

Ensure good vascular supply

Immobilize joints as found

Joint injuries are only aligned if there is nodistal pulse

Apply ice to reduce swelling and pain

Apply compression to reduce swelling

Elevate the extremity if possible

Rigid SplintsRigid Splints


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Figure 26-2

Cannot be changed in

shape and require that

the body part bepositioned to fit the

splint's design

Board splints

Some cardboard splints

Pad before use

Soft or Formable SplintsSoft or Formable Splints


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Can be molded into various shapes to

accommodate the injured body part

Pillows

Blankets

Slings and swathes

Soft or Formable SplintsSoft or Formable Splints


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Figure 26-3

Vacuum splints

Some cardboard splints

Wire ladder splints

Padded, flexible aluminum

splints Inflatable splints

Not to be used for injuries

proximal to knee or elbow

Traction SplintsTraction Splints


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Figure 26-4

Specifically designed for

midshaft femur fractures

Do not apply or maintainsufficient traction to

reduce a femoral

fracture

Do provide enough

traction to stabilize andalign it

Shoulder InjuryShoulder Injury


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Common in the older adult because of

weaker bone structure

Frequently results from a fall on an

outstretched arm


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Anterior fracture or dislocation

Patient often positioned with the affected

arm or shoulder close to the chest

Lateral aspect of the shoulder appears flat

instead of rounded Deep depression between the head of the

humerus and the acromion laterally

( hollow shoulder )

Anterior Dislocation of the ShoulderAnterior Dislocation of the Shoulder


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Figure 26-5 B



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Posterior fracture or dislocation

Patient may be positioned with the arm

above the head

Shoulder Injury ManagementShoulder Injury Management


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Figure 26-6

Assessment of

neurovascular status

Application of a sling andswathe

Application of ice Splinting may need to be

improvised to hold the

injury in place

Humerus InjuryHumerus Injury


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Figure 26-5 C

Common in older adults andchildren

Often difficult to stabilize Associated complications

Radial nerve damage may be

present if a fracture occurs in themiddle or distal portion of thehumeral shaft

Fracture of the humeral neck maycause axillary nerve damage

Internal hemorrhage into the joint

Humerus Injury ManagementHumerus Injury Management


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Figure 26-7

Assessment ofneurovascular status

Traction if there isvascular compromise

Application of a rigid

splint and sling andswathe or splinting theextremity with the arm

extended Application of ice

Elbow InjuryElbow Injury


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Common in children and athletes

Especially dangerous in children

May lead to ischemic contracture with serious

deformity of the forearm and a claw-like hand

Usually involves falling on an outstretchedarm or flexed elbow

Associated complications

Laceration of the brachial artery

Radial nerve damage

Posterior Dislocation of the Elbow Joint

With Marked Deformity

Posterior Dislocation of the Elbow Joint

With Marked Deformity


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Figure 26-5 D

Elbow Injury ManagementElbow Injury Management


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Figure 26-8

Assessment of


Splinting in the positionfound with a pillow, rigid

splint, or sling and

swathe

Application of ice

Radius, Ulna, or Wrist InjuryRadius, Ulna, or Wrist Injury


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Usually result from a fall on an

outstretched arm

Wrist injuries may involve the distal

radius, ulna, or any of the eight carpal

bones Common injury is Colles' fracture

Forearm injuries are common in bothchildren and adults

Severe Open Fracture of ForearmSevere Open Fracture of Forearm


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Figure 26-5 E

Penetration of Forearm Caused by nail gunPenetration of Forearm Caused by nail gun


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Figure 26-5 F

Greenstick Fracture With Marked DeformityGreenstick Fracture With Marked Deformity


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Figure 26-5 G

Fracture of the Distal RadiusFracture of the Distal Radius


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Figure 26-5 H


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Hand (Metacarpal) InjuryHand (Metacarpal) Injury


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Frequently results from:

Contact sports

Violence (fighting) Crushing in industrial context

Common injury - boxer's fracture Results from direct trauma to a closed fist

fracturing the fifth metacarpal bone

Injuries may be associated withhematomas and open wounds

Hand Injury From a Motorcycle CrashHand Injury From a Motorcycle Crash


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Figure 26-5 I

Hand Injury ManagementHand Injury Management


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Assessment of neurovascular status

Splinting with rigid or formable splint in

position of function

Application of ice and elevation

Finger (Phalangeal) InjuryFinger (Phalangeal) Injury


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May be immobilized with foam-filled aluminumsplints or tongue depressors or by taping

injured finger to adjacent one ( buddysplinting)

Finger injuries common

Should not be considered trivial Serious injuries include:

Thumb metacarpal fractures

Any open fracture Markedly comminuted metacarpal or proximal

phalanx fracture

Finger Injury ManagementFinger Injury Management


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Figure 26-10

Assess


Splint

Apply ice and elevate

Lower-Extremity InjuriesLower-Extremity Injuries


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Compared with upper-extremity injuries,lower-extremity injuries are:

Associated with greater wounding forcesand more significant blood loss than upper-extremity injuries

More difficult to manage in the patient withmultiple injuries

May be life threatening Femur fracture

Pelvic fracture

Pelvic FracturePelvic Fracture


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Blunt or penetrating injury to the pelvis mayresult in:

Fracture Severe hemorrhage

Associated injury to the urinary bladder andurethra

Deformity may be difficult to see

Suspect injury to the pelvis based on:

Mechanism of injury Presence of tenderness on palpation of the iliac

crests

Pelvic FracturePelvic Fracture


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Management

High-concentration oxygen administration

Treatment for shock (PASG per protocol)

Full body immobilization on a long spine

board (adequately padded for comfort) Regular monitoring of vital signs

Rapid transport is essential

Hip InjuryHip Injury


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Commonly occurs in older adults because of

a fall

Also occurs in younger patients from major trauma

If the hip is fractured at the femoral head and

neck, the affected leg is usually shortened

and externally rotated

Dislocations of the hip are usually evidenced

by a shortened and rotated leg

Hip Injury ManagementHip Injury Management

A t f


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Figure 26-12

Assessment of


Splinting with a long spineboard and generously

padding patient for comfort

during transport

Slight f lexion of the knee or

padding beneath the knee

may improve comfort

Frequent monitoring of vital

signs

Femur InjuryFemur Injury

U ll lt f j t ( t


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Usually results from major trauma (motorvehicle crashes and pedestrian accidents)

Fairly common result of child abuse Fractures are usually evident from the

powerful thigh muscles producing overriding

of the bone fragments Patient generally has a shortened leg that is

externally rotated and mid-thigh swelling from

hemorrhage Bleeding may be life-threatening

Femur InjuryFemur Injury

Di t f i ht


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Figure 26-11 A

Diameter of right

thigh represents

increased bloodvolume of 2 to 3 L

Femur Injury ManagementFemur Injury Management

High concentration


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Figure 26-13

High-concentrationoxygen administration

Treatment for shock Assessment of


Application of atraction splint Midshaft fracture

Regular monitoring ofvital signs

Knee and Patella InjuryKnee and Patella Injury

Fractures to the knee and fractures and


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Fractures to the knee and fractures and

dislocations of the patella commonly result

from: Motor vehicle crashes

Pedestrian accidents

Contact sports

Falls on a flexed knee

The relationship of the popliteal artery to the

knee joint may lead to vascular injury,

particularly with posterior dislocations

Knee injury from a pedestrian-automobile collisionKnee injury from a pedestrian-automobile collision


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Figure 26-11 B

Knee and Patella Injury ManagementKnee and Patella Injury Management

Assessment of


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Figure 26-14

Assessment of


Splinting in the positionfound with rigid or

formable splint that

effectively immobilizesthe hip and ankle

Application of ice andelevation, if possible

Tibia and Fibula InjuryTibia and Fibula Injury

May result from direct or indirect trauma


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May result from direct or indirect trauma

or twisting injury

If associated with the knee, popliteal

vascular injury should be suspected

Management Assessment of neurovascular status

Splinting with a rigid or formable splint Application of ice and elevation

Fracture of tibia and fibulaFracture of tibia and fibula


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Figure 26-11 C

Open fracture to the lower legOpen fracture to the lower leg


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Figure 26-11 D

Immobilization of the Lower LegImmobilization of the Lower Leg


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Figure 26-15

Foot and Ankle InjuryFoot and Ankle Injury

Fractures and dislocations of the foot


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Fractures and dislocations of the foot

and ankle may result from:

Crush injury

Fall from a height

Violent rotary force

Patient usually complains of point

tenderness and is hesitant to bearweight on the extremity


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Foot that was run over by the wheel of a

railway coach

Foot that was run over by the wheel of a

railway coach


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Figure 26-11 F

Foot and Ankle Injury ManagementFoot and Ankle Injury Management

Assessment of


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Figure 26-16

Assessment ofneurovascular status

Application of aformable splint, suchas a pillow, blanket, orair splint

Application of ice

Elevation

Phalanx InjuryPhalanx Injury

Often caused by stubbing the toe on an


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y gimmovable object

Usually managed by buddy taping the toe toan adjacent toe for support andimmobilization

Management Assessment of neurovascular status

Buddy splinting

Application of ice Elevation

Open FracturesOpen Fractures

Consider any soft tissue wound around


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Consider any soft tissue wound around

a suspected fracture to be evidence of

an open fracture

Fractures may be open in two ways:

From within (as when a bone fragmentpierces the skin)

From without (e.g., after a gunshot wound)

Open FracturesOpen Fractures

An open fracture may have also made


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ope ac u e ay a e a so ade

contact with the skin some distance

from the fracture site

Open fractures are considered a truesurgical emergency because of the

potential for infection

Straightening Angulated Fracturesand Reducing DislocationsStraightening Angulated Fracturesand Reducing Dislocations

Angular fractures and dislocations may


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g y

pose significant problems in splinting,

patient extrication, and transportation

Consult with medical direction beforemanipulation of a fracture or dislocation

to facilitate transport or to improvevascular integrity to an extremity

Limb-Threatening InjuriesLimb-Threatening Injuries

Knee dislocation


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Fracture or dislocation of the ankle

Subcondylar fractures of the elbow

These injuries require rapid transport

for physician evaluation


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ManagementManagement

If transport is delayed or prolonged and


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p y p g

circulation is impaired, an attempt to

reposition a grossly deformed fractureor dislocated joint should be made

The elbow should never be manipulated

in the prehospital setting

MethodMethod

Handle the injury carefully


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Apply gentle, firm traction in the

direction of the long axis of theextremity

If there is obvious resistance toalignment, splint the extremity without

repositioning

Realignment GuidelinesRealignment Guidelines

Only one attempt at realignment should be


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made in the prehospital setting

Only if there is severe neurovascularcompromise (e.g., extremely weak or absent

distal pulses)

Only after consulting with medical direction

Manipulation (if indicated) should be

performed as soon as possible after the injury

Realignment GuidelinesRealignment Guidelines

Should be avoided in the presence of othersevere injuries


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severe injuries

If not contraindicated by other injuries,consider use of analgesics for the

realignment procedure

Assess and document pulse, sensation, and

motor function before and after manipulatingany injured extremity or joint


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Shoulder RealignmentShoulder Realignment

Attempt only in the absence of severe back

i j


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injury

Check circulatory and sensory status

Apply slow, gentle longitudinal traction with

counter traction exerted on the axilla

Slowly (and without force) bring the extremity

to the midline and realign in the anatomical

position while maintaining traction Immobilize with sling and swathe

Hip RealignmentHip Realignment

Apply in-line traction along the shaft of the

f ith th hi d k fl d t 90


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femur with the hip and knee flexed at 90-

degrees Continue with slow and steady traction to

relax the muscle spasm

Successful realignment will be noted by:

A pop into the joint

A sudden relief of pain

Easy manipulation of the leg to full extension

Hip RealignmentHip Realignment

Immobilize the leg in full extension


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with patient positioned on long

spine board Reevaluate pulses and


Ankle RealignmentAnkle Realignment

Apply in-line traction on the talus while

t bili i th tibi


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stabilizing the tibia

Successful realignment will be noted bya sudden rotation to a normal position

Immobilize the ankle in the samemanner as a fracture

Referral of Patients with MinorMusculoskeletal InjuryReferral of Patients with MinorMusculoskeletal Injury

Some patients with minor musculoskeletal

injury (e g a minor sprain) will not require


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injury (e.g., a minor sprain) will not require

EMS transport To make this determination:

Evaluate the need for immobilization

Evaluate the need for an x-ray

Evaluate the need for a physician follow-up visit

versus emergency department assessment

Contact medical direction for advice

Referral of Patients with MinorMusculoskeletal InjuryReferral of Patients with MinorMusculoskeletal Injury

Patients who are not transported to the

h it l h ld i d i h


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hospital should receive advice on how

to care for their injury Patient instruction sheet

If there is any doubt about theseriousness of the patients injury,

transport to the emergency department

for physician evaluation

2008 2nd musculoskeletal trauma als,ils,bls pp cme

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