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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
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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
Musculoskeletal AssessmentMusculoskeletal Assessment
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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
Musculoskeletal AssessmentMusculoskeletal Assessment
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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
General Principles of SplintingGeneral Principles of Splinting
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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
General Principles of SplintingGeneral Principles of 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
General Principles of SplintingGeneral Principles of Splinting
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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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Shoulder InjuryShoulder Injury
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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
Shoulder InjuryShoulder Injury
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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
neurovascular status
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
neurovascular status
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
neurovascular status
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
neurovascular status
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
neurovascular status
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
neurovascular status
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