bledsoe et al., paramedic care principles & practice volume 4: trauma © 2006 by pearson...

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 7Musculoskeletal Trauma

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Topics

Introduction to Musculoskeletal Trauma

Anatomy and Physiology of the Musculoskeletal System

Pathophysiology of the Musculoskeletal System

Musculoskeletal Injury Assessment

Musculoskeletal Injury Management

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction to Musculoskeletal Injuries

Millions of Americans experience annually

Multiple MOI– Falls, crashes, violence, etc.– Multi-system trauma

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Musculoskeletal System

Skeletal Tissue and Structure– Gives the body its structural form– Protects vital organs– Promotes efficient movement despite the

forces of gravity– Stores salts and other materials needed

for metabolism– Produces red blood cells

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal System

Bone Structure– Diaphysis– Epiphysis

End of a long bone– Metaphysis

Between epiphysis and diaphysisGrowth plate

– Medullary canalContains bone marrow

– PeriosteumFibrous covering of diaphysis

– CartilageConnective tissue that provides a smooth articulation surface for other bones

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Musculoskeletal System

Joint Structure– Joint

Where bones interact

– SynarthrosisA joint that does not permit movement

– Diarthroses (synovial joints)Monaxial: hinge or pivot jointsBiaxial: gliding, sliding, or saddle jointsTriaxial: ball and socket joints

– Ligaments– Joint capsule

Synovial fluid

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Joint Structure (1 of 2)

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Joint Structure (2 of 2)

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Musculoskeletal System (1 of 3)

Skeletal Organization– 206 bones– Axial skeleton

Head, thorax, and spine

– Appendicular skeletonUpper extremities

Lower extremities

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Bone Aging– Birth to adult (18–20)

Transition from flexible to firm bone

– Adult to elderly (40+)Reduction in collagen matrix and calcium salts

Diminution of bone strength

Spinal curvature

Anatomy and Physiology of the Musculoskeletal System (2 of 3)

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Musculoskeletal System (3 of 3)

Types of Muscles– Smooth– Striated– Cardiac

Muscular Tissue and Structure– 600 muscle groups

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Muscles

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal System

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Muscular Injury

Contusion

Compartment Syndrome

Penetrating Injury

Fatigue

Muscle Cramp

Muscle Spasm

Strain

Pathophysiology of the Musculoskeletal System (1 of 5)

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of the Musculoskeletal System (2 of 5)

Joint Injury– Sprain– Subluxation– Dislocation

Bone Injury– Open fracture– Closed fracture– Hairline fracture– Impacted fracture

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of the Musculoskeletal System (3 of 5)

Pediatric Considerations– Flexible nature

Geriatric Considerations– Osteoporosis

Pathological Fractures– Pathological diseases

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of the Musculoskeletal System (4 of 5)

General Considerations with Musculoskeletal Injuries– Neurological compromise– Decreased stability– Muscle spasm

Bone Repair Cycle– Osteocytes produce osteoblasts– Deposition of salts– Increasing strength of matrix

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of the Musculoskeletal System (5 of 5)

Inflammatory and Degenerative Conditions– Bursitis– Tendinitis– Arthritis

OsteoarthritisDegenerative

Rheumatoid arthritisChronic, systemic, progressive, debilitating

GoutInflammation of joints produced by accumulation of uric acid crystals

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Assessment (1 of 2)

Scene Size-upInitial Assessment– Categories of urgency

Life- and limb-threatening injuryLife-threatening injury and minor musculoskeletal injuryNon-life-threatening injuries but serious musculoskeletal injuriesNon-life-threatening injuries and only isolated minor musculoskeletal injuries

Rapid Trauma Assessment– Only press on pelvis if no clinical signs of injury are present such

as pain.

Focused H&P– 6 Ps: Pain, Pallor, Paralysis, Paresthesia, Pressure, Pulses

Detailed Physical ExamOngoing AssessmentSports Injury Consideration

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Assessment (2 of 2)

Scene Size-up– Clues to specific injuries.– Pelvic fractures or bilateral femur

fractures are “Load and Go.”– Control major bleeding.– History may suggest other injuries.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Detailed Exam of Extremities

Deformity

Contusions

Abrasions

Penetrations

Burns

Tenderness

Lacerations

Swelling

Also check PMS.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management (1 of 2)

General Principles– Protecting open wounds– Positioning the limb– Immobilizing the injury– Checking neurovascular function

PulsePalpateUtilize pulse oximetry

MotorSensation

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management (2 of 2)

Splinting Devices– Rigid splints– Formable splints

Vacuum splintsAir Splints

– Soft splints– Traction splints– Other splinting aids

Cravats or Velcro splints

Fracture CareJoint CareMuscular and Connective Tissue Care

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Care for Specific Fractures (1 of 4)

Pelvis– Scoop stretcher– Pelvic sling device

PASG as a reserve device only

– Fluid resuscitation

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Care for Specific Fractures (2 of 4)

Femur Fractures– Traction splints

Contraindicated in hip/knee injuries

– PASG– High-force injury– High potential for shock

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Care for Specific Fractures (3 of 4)

Tibia-Fibula Fractures– Frequently open fractures.– Cover bone ends with moist dressing.– Depending on level of fracture, use:

Rigid splint

Air splint

Pillow

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Care for Specific Fractures (4 of 4)

ClavicleMost frequently fractured bone in the body

Transmitted to 1st and 2nd rib

Alert for lung injury

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management

Care for Specific Joint Injuries– Hip– Knee– Ankle– Foot– Shoulder– Elbow– Wrist/Hand– Finger

Be alert for neurological compromise.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hip Fractures

Common in the elderly.

May be able to support weight.– Ability to walk does not rule out fracture.

Leg often externally rotated.

May refer pain to the knee.

Use other leg for splint.

Use vacuum mattress if available.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hip Dislocation

Orthopedic emergency

Posterior dislocation most common

Hip flexed and leg rotated internally

Severe pain on attempts to straighten

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hip Dislocation Management

Splint in most comfortable position.

Document sensation and pulse.

Prompt transport.

Be alert for associated knee injuries or fractures.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Knee Fracture or Dislocation

Orthopedic emergency

Frequently causes vascular injury

Dislocation associated with 50% rate of amputation of leg

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Knee Fracture or DislocationManagement

Obvious dislocation without distal pulse:– Apply gentle traction along the long axis

of the joint.

If gentle traction does not restore the pulse:– Splint in place.

Prompt transport.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Foot or Hand Injury

Common industrial injury.

Often disabling.

Rarely life threatening.

Splint foot with pillow.

Splint hand in position of function.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Shoulder Injuries

AC Separation– Sling and swathe.

Shoulder Dislocation– Use pillow with sling and swathe.

Fracture– Use sling and swathe.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Elbow Injury

Fracture or dislocation may cause neurovascular injury.

Splint in position found.

Transport promptly.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Forearm/Wrist Injury

Rigid Splint– Keep hand in “position of function.”

Air Splint– May be hard to reassess circulation.

Pillow

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management

Soft and Connective Tissue Injuries– Tendon– Ligament– Muscle

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury ManagementMedications (1 of 4)

Nitrous Oxide– 50% O2:50% N2O– Non-explosive– Effects dissipate in 2–5

minutes– Easily diffused into air-

filled spaces in body– Dose

Inhaled and self administered

– Onset1–2 minutes

Diazepam– Benzodiazepine– Antianxiety– Analgesic– Dose

5–15 mg titrated

– Onset10–15 minutes

– Duration15–60 minutes

– Counter agentFlumazenil

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury ManagementMedications (2 of 4)

Morphine Sulfate– Opiate alkaloid.– Reduces vascular volume and cardiac

preload.– Do not administer to hypovolemic

patients.– Dose:

2mg IVP slow

– Counter agent:Narcan

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury ManagementMedications (3 of 4)

Meperidine– Demerol– Narcotic analgesic– Dose

50–100 mg

– Counter AgentNarcan

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury ManagementMedications (4 of 4)

Sublimaze– Fentanyl– Synthetic opioid– Equivalent to morphine– Dose

25–50 mg SIVP followed by an additional 25 mg as needed

– OnsetLess than a minute

– Duration3–6 hours

– ConsiderationsIf given too rapidly, chest wall rigidity may ensue, leading to respiratory compromise.

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management

Other Injury Considerations– Pediatric musculoskeletal injury– Athletic musculoskeletal injury– Patient refusals and referral– Psychological support

Bledsoe et al., Paramedic Care Principles & Practice Volume 4: Trauma© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary

Introduction to Musculoskeletal Trauma

Anatomy and Physiology of the Musculoskeletal System

Pathophysiology of the Musculoskeletal System

Musculoskeletal Injury Assessment

Musculoskeletal Injury Management