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Musculoskeletal

Skeletal System

The Skeletal System

Consists of: Bones Cartilage Ligaments

Connect Bone to Bone Tendons

Connect Muscle to Bone

Accounts for 20% of body weight

They are living tissue

Functions

Support Supports organs and against gravity

Protection Protects soft organs underneath

Movement Muscles attached provide movement

Storage Inner matrix has Ca salts, Fat in Yellow Bone

Marrow Blood Cell Formation

Hematopoesis in the Red Bone Marrow

Structure Types:

Compact Spongy

Classifications Long

Femur, Ulna, Radius, Tibia, Fibula Short

Tarsals and Carpals Flat

Cranial bones Irregular

Vertebrae

General Features of the Long Bone

Diaphysis

Epiphysis

Epiphyseal Plate

PeriosteumMedullary Cavity

Endosteum

Each bone has surface markings that make it unique

Contains 206 named bones

Two divisions Axial Skeleton Appendicular Skeleton

Divisions

Axial Skeleton 80 bones form the vertical axis Include:

Cranium Vertebrae Sternum Ribs

Divisions

Axial Skeleton

Skull 28 separate bones

Hyoid bone

Axial Skeleton

Vertebral column Consists of approximately 33 bones divided

into 5 regions 7 cervical vertebrae

C1 (Atlas) – Yes C2 (Axis) - No

12 thoracic vertebrae 5 lumbar vertebrae 1 sacral bone (5 fused vertebrae) 1 coccygeal bone (3-5 fused vertebrae)

Thoracic Cage

Protects vital organs in the thorax Prevents collapse of the thorax during

respiration 12 pairs of ribs Sternum

Manubrium Body Xiphoid process

126 Bones Consists of the bones of the upper and

lower extremities and their girdles Pectoral girdle

Comprised of the scapula and clavicle Attaches upper limbs to the axial skeleton

Appendicular Skeleton

Upper Extremity

Humerus Second largest

bone in the body Radius and Ulna Wrist

Pelvic Girdle

Attaches legs to trunk Consists of two hip bones (coxae) Acetabulum

Legs

Femur Longest bone in the body Head articulates with the acetabulum Articulates distally with patella

Tibia Larger than fibula and supports most

of leg's weight Distal end forms lateral malleolus,

forming medial side of ankle joint Fibula

Does not articulate with femur Does articulate with tibia Distal end forms lateral malleolus,

forming lateral aspect of ankle joint

Foot

Consists of tarsals, metatarsals, and phalanges

Talus articulates with tibia and fibula

Calcaneus

Every bone (except the hyoid bone) connects to at least one other bone

Three major classifications of joints Fibrous joints Cartilaginous joints Synovial joints

Biomechanics of Movement

Consist of two bones--united by fibrous tissue—that have little or no movement

Sutures (seams between flat bones)

Fibrous Joints

Unite two bones by means of hyaline cartilage (synchondroses) or fibrocartilage (symphyses)

Synchondroses Slight motion (between ribs and sternum)

Symphysis Slight motion, flexible (symphysis pubis)

Cartilaginous Joints

Synovial 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

Muscular System

Characteristics

Excitability The ability to receive and respond to stimulus

Contractility The ability to contract

Extensibility The ability to stretch (opposing pairs)

Elasticity The ability to recoil to original shape

Functions

Movement Posture Joint stability Heat Production

Types

Smooth Involuntary Found in the walls of organs Ex: Intestinal tract

Skeletal Voluntary

Cardiac Found only in cardiac muscle

Structure

As a whole each muscle may be made up of hundreds of muscle fibers

Fascia surrounds and separates each muscle

Each muscle is surrounded by a protective sheath called epimysium which divides the muscle into compartments

Each compartment contains a bundle of fibers called a fasciculus surrounded by a layer of tissue called perimysium

Each fiber in the fasciculus is surrounded by a layer of tissue called the endomysium

The coverings also contain blood vessels and nerves

Structure

Muscle Fibers Each fiber is a cylindrical cell The cell membrane is called the sacrolemma The cytoplasm is the sarcoplasm A special Endoplasmic Reticulum in the sarcoplasm

is called the sarcoplasmic reticulum The sarcolemma has multiple nuclei and

mitochondria (for energy production) Inward extensions of the sacrolemma are called T-

tubules

Structure

Muscle Fibers

SACROMERE

Nerve & Blood Supply

Have an abundant supply Before a muscle can contract it needs a

stimulus This requires ATP Blood supply deliver O2 and nutrients to

produce this and remove the waste products One Artery and One Vein accompany each

nerve

Contraction

Stimulated by specialized nerve cells called motor neurons

The motor neuron and muscle(s) is called a motor unit

Where the axon of the neuron meets the muscle is called the neuromuscular junction

Between the two is a small depression in the muscle membrane called the synaptic cleft

Contraction

ACh is contained within the synaptic vesicles of the axon

Receptors for ACh are in the sacrolemma The combination results in a stimulus for

contraction (an impulse) which travels along the sacrolemma into the T-tubules where a physiological change occurs causing a contraction

The enzyme acetylcholinesterase deactivates the ACh at the synaptic cleft

Sacromere Contraction

In a relaxed muscle fiber myosin receptor sites on the actin are inactive

Heads on the myosin are also inactive and are bound to ATP

Ca is stored in the sarcoplasmic reticulum and has a low concentration in the sarcoplasm

An impulse into the T-tubule cause release of Ca from the SR into the sarcoplasm

This rapid influx changes configuration of troponin on the actin fibers which exposes receptor sites

Sacromere Contraction

Simultaneously ATP is broken down to ADP which gives energy to the myosin

This energy allows it to interact with the actin The myosin heads bind forming cross-bridges and

rotate pulling the actin towards the center of the myosin (Power stroke)

This pulls the Z line closer together shortening the sacromere

This does not shorten the myofilament New ATP on myosin reverse the reaction This is the “Sliding Filament Theory”

Sacromere Contraction

When the stimulation ceases, Ca is actively transported into the SR

This causes the receptor sites to close and ceasing the contraction

Follows the All-or-none Principle, which is basically: A sufficient stimulus is need to cause a contraction

(threshold stimulus) A greater stimulus will not produce greater contraction Not enough will elicit no response (sub-threshold

stimulus)

Whole Muscle Contraction

Does not follow All-or-none Varies due to work load Increase contraction is achieved by motor unit

summation and wave summation A single stimulus causes a twitch (lab setting) 3 stages of contraction

lag phase contraction relaxation

Whole Muscle Contraction

A stimulus given during relaxation phase will cause stronger contraction, and continues to build to form a smooth contraction called tetany (multiple wave summation)

Treppe (staircase) shows an increase in force with a stimulus of same intensity

Muscle tone is the continued state of partial contractions of the muscles (needed for posture and temp)

If movement occurs it is an isotonic contraction If there is no movement then it is isometric

Energy Sources

Initial Source ATP for the cross-bridge and active transport Last only 6 seconds

Second Source Creatine Phospate is used to instantaneously

give its energy to ADP to synthesis ATP If ATP is in excess it will convert to Creatine

phosphate to store for later use Lasts only 10 seconds

Energy Sources

Third Stage Muscles use fatty acids and glucose for energy Fatty acids found in blood Glucose is a derivative of the glycogen found in the muscle If oxygen available then the fats and glucose are broken

down with aerobic metabolism (20 times more production)

Fatty Acids or glucose + O2 → CO2 + H20 + ATP If oxygen is not available then glucose is the primary

source of energy (anaerobic metabolism – happens at a faster rate)

Glucose → lactic acid + ATP

Energy Sources Oxygen storage

Red fibers have myoglobin which has iron to bind with O2 White Fibers do not contain myoglobin

Lactic Acid Excessive lactic acid is send to the liver when O2 is available and

converted and stored as glycogen

Oxygen Debt After strenuous exercise using anaerobic metabolism, ATP and creatine

phosphate have to be replaced, this requires O2 Is the additional O2 needed to do this after exercise

Musculoskeletal Injury

Injury to Muscle

Can occur due to: Overexertion where fibers are broken With trauma muscles can be bruised,

crushed, cut, or even torn even without a break in the skin.

Injured muscles tend to be: Swollen, tender and painful, weak

Classification of MS Injuries

Injuries that result from traumatic forces include: Fractures Sprains Strains Dislocations

Complications

Hemorrhage Instability Loss of tissue Simple laceration and contamination Interruption of blood supply Nerve damage Long-term disability

Ligaments BONE to BONE

Tendons MUSCLE to BONE

Sprain is an injury to a ligament Strains are injuries to tendons or muscles Dislocations are bones of a joint that are separated

from normal position of use

Sprains, Strains and Dislocations

Sprains

A partial tearing of a ligament caused by a sudden twisting or stretching of a joint beyond its normal range of motion Ankle and knees are most common

Sprains are graded by severity: First degree

Ligaments are stretched but not torn Can put weight on the ankle

Second degree Ligament is partially torn, pain and swelling are greater Painful with weight

Third degree Cannot handle weight

Strains

An injury to the muscle or its tendon from overexertion or overextension

Commonly occur in the back and arms (welcome to EMS)

May be accompanied by significant loss of function

Severe strains may cause an avulsion of the bone from the attachment site

Dislocations

Occur when the normal articulating ends of two or more bones are displaced Luxation (a complete dislocation) Subluxation (Incomplete dislocation)

Suspect a joint dislocation if deformity or does not move with normal range of function

All dislocations can result in damage and instability

Due to limited diagnostic equipment, field diagnosis is not necessary

They are all treated as fractures until proven otherwise

Treatment

Treatment

Most BONE, JOINT, and MUSCLE injuries will benefit from RICE:

Rest

Ice

Compression

Elevation

Direct Force Indirect Force Twisting Forces Muscle Contractions Pathological

Common MOI’s

Any break in the continuity of the bone Open Fracture

An open wound leading to the break The bone may or may not be exposed

Closed Fracture No wound in the are of the break

Simple Single fracture of the bone

Complex Multiple fractures of the bone

Fractures

Swelling Discoloration Deformity Pain

On palpation or movement

Crepitus Loss of function

Decreased ROM False movement

Decreased of absent sensory perception or circulation distal to the injury

Signs and Symptoms

Types of Fractures

Epiphyseal Fracture (Growth plate)

Assessment

Scene Assessment Primary survey

Rule out life threatening injuries and treat first remember distracting injuries

Identify Six P’s of MS assessment

Stabilize Expose

Compare to uninjured extremity Assess CMS Splint Reassess CMS

Pain management (Call for ALS if required)

Six P’s of MS Assessment

Pain Pain on palpation Pain on movement

Pallor Pale skin or poor capillary refill

Paresthesia Pins and needles sensation

Pulses Diminished or absent

Paralysis Pressure

Splinting

The goal of splinting is Immobilization of injured body part

Helps alleviate pain Decreases tissue injury, bleeding and

contamination of an open wound Simplifies and facilitates transport

Splinting

Splint joints above and below the fracture Cover open wounds to reduce

contamination Check CMS before and after Immobilize joints in position found (ensure

good vascular supply) Cold applied to reduce swelling and pain

(heat is used later for healing)

Rigid Splints

Cannot be changed in shape Require the body part to be positioned

to fit Board splints Cardboard splints

Can be padded to accommodate anatomical shape and comfort

Soft or Formable Splints

Can be molded into various shapes to accommodate injured part Pillows Blankets Slings and swathes Vacuum splints Wire ladder spliints Flexible aluminum splints (SAM splints) Inflatable splints

Traction Splints

Specifically designed for Mid-Shaft femur fractures

Provide enough traction to stabilize and align a fracture

Upper-Extremity Injuries

Shoulder Injury

Common in the older adult because of weaker bone structure Frequently results from a fall on an

outstretched arm

Shoulder Injury

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”) Posterior fracture or dislocation

Patient may be positioned with the arm above the head

Shoulder Injury – Management

Assessment of neurovascular status

Application of a sling and swathe

Application of a cold pack

Splinting may need to be improvised to hold the injury in place

Humerus Injury

Common in older adults and children Often difficult to stabilize Associated complications

Radial nerve damage may be present if a fracture occurs in the middle or distal portion of the humeral shaft

Fracture of the humeral neck may cause axillary nerve damage

Internal hemorrhage into the joint

Humerus Injury – Management

Assessment of neurovascular status

Traction if there is vascular compromise

Application of a rigid splint and sling and swathe or splinting the extremity with the arm extended

Application of a cold pack

Elbow Injury

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 outstretched arm

or flexed elbow Associated complications

Laceration of the brachial artery Radial nerve damage

Elbow Injury – Management

Assessment of neurovascular status

Splinting in the position found with a pillow, rigid splint, or sling and swathe

Application of a cold pack

Radius, Ulnar, or Wrist Injury

Usually result from a fall on an outstretched arm

Wrist injuries may involve the distal radius, ulnar, or any of the eight carpal bones Common injury is Colles' fracture

Forearm injuries are common in both children and adults

Radius, Ulnar, or Wrist Injury – Management

Assessment of neurovascular status

Splinting in the position found with rigid or formable splints or sling and swathe

Application of a cold pack and elevation

Hand (Metacarpal) Injury

Frequently results from: Contact sports Violence (fighting) Crushing in industrial context

A common injury is boxer's fracture Results from direct trauma to a closed fist

fracturing the fifth metacarpal bone Injuries may be associated with hematomas

and open wounds

Hand Injury – Management

Assessment of neurovascular status Splinting with rigid or formable splint in

position of function Application of a cold pack and elevation

Finger (Phalangeal) Injury

May be immobilized with foam-filled aluminum splints or tongue depressors or by taping injured finger to adjacent one (“buddy splinting”)

Finger injuries are common Should not be considered trivial

Serious injuries include: Thumb metacarpal fractures Any open fracture Markedly comminuted metacarpal or proximal phalanx

fracture

Finger Injury – Management

Assess neurovascular status Splint Apply cold pack and elevate

Lower-Extremity Injuries

Compared with upper-extremity injuries, lower-extremity injuries are: Associated with greater wounding forces and

more significant blood loss than upper-extremity injuries

More difficult to manage in the patient with multiple injuries

May be life threatening Femur fracture Pelvic fracture

Pelvic Fracture

Blunt or penetrating injury to the pelvis may result in: Fracture Severe hemorrhage Associated injury to the urinary bladder and urethra

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 Fracture

Management High-concentration oxygen administration Treatment for shock Full body immobilization on a long spine

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

Hip Injury

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 – Management

Assessment of neurovascular status Splinting with a long spine board and

generously padding patient for comfort during transport

Slight flexion of the knee or padding beneath the knee may improve comfort

Frequent monitoring of vital signs

Femur Injury

Usually results from major trauma (motor vehicle 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 Injury – Management

High-concentration oxygen administration

Treatment for shock Assessment of neurovascular status Application of a traction splint Regular monitoring of vital signs

Knee and Patella Injury

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 and Patella Injury – Management

Assessment of neurovascular status Splinting in the position found with rigid or

formable splint that effectively immobilizes the hip and ankle

Application of a cold pack and elevation, if possible

Tibia and Fibula Injury

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 a cold pack and elevation

Foot and Ankle Injury

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 bear weight on the extremity

Foot and Ankle Injury – Management

Assessment of neurovascular status Application of a formable splint, such

as a pillow, blanket, or air splint Application of a cold pack Elevation

Phalanx Injury

Often caused by “stubbing” the toe on an immovable object

Usually managed by buddy taping the toe to an adjacent toe for support and immobilization

Management Assessment of neurovascular status Buddy splinting Application of cold pack Elevation

Management

As a rule, fractures and dislocated joints should be immobilized in the position of injury and the patient transported to the emergency department for realignment (reduction)

If transport is delayed or prolonged and circulation is impaired, an attempt to reposition a grossly deformed fracture or dislocated joint should be made

The elbow should never be manipulated in the prehospital setting

Method

Handle the injury carefully Apply gentle, firm traction in the

direction of the long axis of the extremity

If there is obvious resistance to alignment, splint the extremity without repositioning

Realignment Guidelines

Only one attempt at realignment should be made in the prehospital setting

Only if there is severe neurovascular compromise (e.g., extremely weak or absent distal pulses)

May consult OLMC Manipulation (if indicated) should be

performed as soon as possible after the injury

Realignment Guidelines

Should be avoided in the presence of other 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 manipulating any injured extremity or joint

Spinal Injuries

Hyperextension Flexion Compression Lateral Distraction Penetration Flexion-Rotation

Common MOI’s

Traditional Spinal Assessment Criteria

Traditional criteria have focused on mechanism of injury (MOI) with spinal immobilization considerations for two specific patient groups: Unconscious accident victims Any patients with a “motion” injury

Covers all patients with a potential for spinal injury Not always practical in the prehospital setting

Prehospital Assessment

Prehospital assessment can be enhanced by applying clear, clinical criteria for evaluating spinal cord injury that includes the following signs and symptoms (in the absence of other injuries, altered mental status, or use of intoxicants):

Pain Tenderness Painful with or without movement Deformity Cuts/bruises over spinal area Paralysis Paresthesias Weakness Priaprism (usually a total transection of the cord) SOB with very little Chest Expansion Incontinence

MOI or Nature of Injury

When determining mechanism of injury in a patient who may have spinal trauma, classify the MOI as: Positive Negative Uncertain

When combined with clinical criteria for spinal injury, can help identify situations in which spinal immobilization is appropriate

Positive MOI

Forces exerted on the patient are highly suggestive of spinal cord injury

Always require full spinal immobilization Examples:

High-speed motor vehicle crashes Falls greater than three times the patient’s height Violent situations occurring near the patient’s spine Sports injuries Other high-impact situations

Positive MOI

In the absence of signs and symptoms of SCI, some medical-direction agencies may recommend that a patient with a positive MOI not be immobilized Recommendations will be based on the

paramedic’s assessment when: Patient history is reliable There are no distraction injuries

Negative MOI

Includes events where force or impact does not suggest a potential for spinal injury In the absence of SCI signs and symptoms, does

not require spinal immobilization Examples:

Dropping an object on the foot Twisting an ankle while running Isolated soft tissue injury

Uncertain MOI

When the impact or force involved in the injury is unknown or uncertain, clinical criteria must be used to determine need for spinal immobilization

Examples: Tripping or falling and hitting the head Falls from 2 to 4 feet Low-speed motor vehicle crashes (“fender

benders”)

Assessment of Uncertain MOI

Ensure that the patient is “reliable” Reliable patients are calm, cooperative, sober, alert,

and oriented Examples of “unreliable” patients:

Acute stress reactions from sudden stress of any type Brain injury Intoxicated Abnormal mental status Distracting injuries Problems communicating

Spinal Injury

Frequent causes of spinal trauma: Axial loading Extremes of flexion, hyperextension, or hyperrotation Excessive lateral bending Distraction

May result in stable and unstable injuries based on: Extent of disruption to spinal structures Relative strength of the structures remaining intact

Axial Loading (Vertical Compression)

Results when direct forces are transmitted along the length of the spinal column

May produce compression fracture or a crushed vertebral body without SCI Most commonly occur at T12 to L2

Flexion, Hyperextension, and Hyperrotation

Extremes in flexion, hyperextension, or hyperrotation may result in: Fracture Ligamentous injury Muscle injury

Spinal cord injury is caused by impingement into the spinal canal by subluxation of one or more cervical vertebrae

Lateral Bending

Excessive lateral bending may result in dislocations and bony fractures of cervical and thoracic spine Occurs as a sudden lateral impact moves

the torso sideways Initially, head tends to remain in place

until pulled along by the cervical attachments

Distraction

May occur if the cervical spine is suddenly stopped while the weight and momentum of the body pull away from it May result in tearing and laceration of the

spinal cord

Less Common Mechanisms of Spinal Injury

Blunt trauma Electrical injury Penetrating trauma

Classifications of Spinal Injury

Sprains Strains Fractures Dislocations Sacral fractures Coccygeal fractures Cord injuries

Spinal Injuries

All patients with suspected spinal trauma and signs and symptoms of SCI should be immobilized Avoid unnecessary movement

An unstable spine can only be ruled out by radiography or lack of any potential mechanism for the injury

Assume Spinal Injury:

Significant trauma and use of intoxicating substances

Seizure activity Complaints of pain in the

neck or arms (or paresthesia in the arms)

Neck tenderness on examination

Unconsciousness because of head injury

Significant injury above the clavicle

A fall more than three times the patient's height

A fall and fracture of both heels (associated with lumbar fractures)

Injury from a high-speed motor vehicle crash

Spinal Injury

Damage produced by injury forces can be further complicated by: Patient's age Preexisting bone diseases Congenital spinal cord anomalies

Spinal cord neurons do not regenerate to any great extent

Hyperflexion Sprains and Strains

Hyperflexion sprains Occur when the posterior ligamentous

complex tears at least partially Hyperextension strains (whiplash)

Common in low-velocity, rear-end automobile collisions

Signs and symptoms Management

Fractures and Dislocations

Most frequently injured spinal regions in descending order: C5-C7 C1-C2 T12-L2

Of these, the most common are wedge-shaped compression fractures and "teardrop" fractures or dislocations

Sacral and Coccygeal Fractures

Most serious spinal injuries occur in the cervical, thoracic, and lumbar regions

Patients frequently complain that they have “broken their tailbone” Experience moderate pain from the mobile

coccyx

Sacral and Coccygeal Fractures

Fractures through the foramina of S1 and S2 are fairly common and may compromise several sacral nerve elements May result in loss of perianal sensory motor

function and in bladder and sphincter disturbances

Sacrococcygeal joint may also be injured because of direct blows and falls

Classification of Cord Injuries

Primary injuries - occur at time of impact

Secondary injuries - occur after the initial injury and can include: Swelling Ischemia Movement of bony fragments

Cord Injuries

The spinal cord can be concussed, contused, compressed, and lacerated

Severity of these injuries depends on: Amount and type of forced that produced

them Duration of the injury

Cord Lesions

Lesions (transections) of the spinal cord are classified as complete or incomplete

Complete Cord Lesions

Usually associated with spinal fracture or dislocation Total absence of pain, pressure, and joint sensation

and complete motor paralysis below the level of injury

Results in: Quadriplegia

Injury at the cervical level Loss of all function below injury site

Paraplegia Injury at the thoracic or lumbar level Loss of lower trunk only

Complete Cord Lesions

Autonomic dysfunction may be associated with complete cord lesions

Manifestations of autonomic dysfunction: Bradycardia Hypotension Priapism Loss of sweating and shivering Poikilothermy (look it up!) Loss of bowel and bladder control

Incomplete Lesions

Central cord syndrome Commonly seen with hyperextension or

flexion cervical injuries Characterized by greater motor impairment

of the upper than lower extremities Signs and symptoms

Paralysis of the arms Sacral sparing

Incomplete Lesions

Anterior cord syndrome Usually seen in flexion injuries Caused by:

Pressure on the anterior aspect of the spinal cord by a ruptured intervertebral disk

Fragments of the vertebral body extruded posteriorly into the spinal canal

Signs and symptoms Decreased sensation of pain and temperature below level

of lesion Intact light touch and position sensation Paralysis

Incomplete Lesions

Brown-Sequard syndrome A hemi-transection of the spinal cord May result from:

A ruptured intervertebral disk Encroachment on the spinal cord by a fragment of

vertebral body, often after knife or missile injuries

In the classic presentation, pressure on half the spinal cord results in:

Weakness of the upper and lower extremities on ipsilateral side

Loss of pain and temperature on contralateral side

Assessment

Priorities: Scene survey Assessment of airway, breathing, and

circulation Preservation of spinal cord function and

avoiding secondary injury to the spinal cord

Assessment

Prevent secondary injury that could result from: Unnecessary movement Hypoxemia Edema Shock

Prehospital Goals

Maintain a high degree of suspicion for spinal injury Scene survey Kinematics History of the event

Provide early spinal immobilization Oxygen administration Rapidly correct any volume deficits

Neurological Examination

After managing life-threatening problems encountered in the initial assessment, perform a neurological exam May be done at the scene or en route to the

hospital if the patient requires rapid transport Document findings

Components of neurological examination: Motor and sensory findings Reflex responses

Dermatomes

Dermatomes correspond to spinal nerves The following landmarks may be useful for a quick

sensory evaluation in the prehospital setting: C2 to C4 dermatomes provide a collar of sensation around

the neck and over the anterior chest to below the clavicles T4 dermatome provides sensation to the nipple line T10 dermatome provides sensation to the umbilicus S1 dermatome provides sensation to soles of the feet

Other Methods of Evaluation

Visual inspection may indicate presence of injury and its level Transection of the cord above C3 often

results in respiratory arrest Lesions that occur at C4 may result in

paralysis of the diaphragm Transections at C5-C6 usually spare the

diaphragm and permit diaphragmatic breathing

Spinal Injury

Absence of neurological deficits does not rule out significant spinal injury If a spinal injury is suspected, the patient's

spine must be protected Patient's ability to walk should not be a

factor in determining need for spinal precautions

Spinal Immobilization

Primary goal is to prevent further injury Treat the spine as a long bone with a joint at

either end (the head and pelvis) Always use “complete” spinal immobilization

Spinal immobilization begins in the initial assessment Must be maintained until the spine is completely

immobilized on a long backboard

Spinal Stabilization Techniques

Immediately on recognizing a possible or potential spine injury, manually protect the patient's head and neck Head and neck must be maintained in line

with the long axis of the body

Rigid Cervical Collars

Designed to limit (not stop) motion of the head and neck

Available in many sizes (or are adjustable) Choosing the appropriate size reduces flexion or

hyperextension Must not inhibit patient's ability to open his or her

mouth or to clear his or her airway in case of vomiting

Must not obstruct airway passages or ventilations Should be applied only after the head has been

brought into a neutral in-line position

To measure the collar Check the distance from the angle of the

jaw to the top of the Trapezius muscle with your hand

Match the appropriate finger width to the C-collar and select appropriate size

C-Collars

Short Spine Boards

Used to splint the cervical and thoracic spine

Vary in design and are available from many equipment manufacturers

Generally used to provide spinal immobilization in situations in which the patient is in a sitting position or a confined space

After short spine board immobilization, the patient is transferred to a long spine board for complete spinal immobilization

Rapid Extrication

Steps may vary depending on: Size and make of the vehicle Patient’s location inside the vehicle

Procedure

Long Spine Board

Available in a variety of types including: Plastic and synthetic spine boards Metal alloy spine boards Vacuum mattress splints Split litters (scoop stretchers) that must be

used with a long spine board

Long Spine Board - Supine Patient

Immobilizing the torso to a long spine board must always precede immobilization of the head

Torso must not be allowed to move up, down, or to either side

Place straps at the: Shoulders or chest Around the mid-torso Across the iliac crests to prevent movement of the lower

torso

After immobilization of torso, immobilize head and neck in a neutral, in-line position

Long Spine Board - Supine Patient

Noncompressible padding should be added as needed before securing the head

Padding (if needed) should be firm and extend the full length and width of the torso from the buttocks to the top of the shoulders

Long Spine Board - Supine Patient

Children have proportionally larger heads than adults May require padding under the torso to

allow the head to lie in a neutral position on the board

Long Spine Board - Supine Patient

Secure the head to the device by placing commercial pads or rolled blankets on both sides of the head and securing with: Included straps 2 to 3 inch tape strips

You must be comfortable with both types!

Tape

When apply tape, use a minimum of 3 complete wraps while apply gentle but firm traction on the tape

Use a continuous loop (do not break at each section) Order of taping

Secure thoracic cage Hands/arms free for the conscious patient Hands/arms secured for the unconscious patient

Secure pelvis Secure lower extremities (thighs and lower limbs) Secure head

Straps

Need a minimum of 3 straps (4 or more is preferred) Straps should be applied in same order as tape Use cross over technique

Right shoulder to left hip Left shoulder to right hip

Standing Take Down

Used to immobilize the standing patient Should be done in a quick efficient

manor

Techniques… Two person Three person

Immobilizing Pediatric Patients

Prehospital care should include: Manual in-line immobilization Rigid cervical collar Long spinal immobilization device

Immobilization devices available from various equipment manufacturers If unavailable, adult long spine boards may be used

for full spinal immobilization

Helmet Issues

Purpose of helmets is to protect the head and brain, not the neck Leaves the cervical spine vulnerable to injury

Types of helmets Full-face or open-face designs

Used in motorcycling, bicycling, rollerblading, and other activities

Helmets designed for sports such as football and motor-cross

Helmet Issues

When determining the need to remove a helmet consider: Athletic trainers may have special equipment (and

training) to remove face-pieces from sports helmets Allows easier access to the patient’s airway

Sports garb (e.g., shoulder pads) could further compromise the cervical spine if only the helmet were removed

Firm fit of a helmet may provide firm support for patient’s head

Helmet Removal

Removing a helmet from an injured patient in the prehospital setting (vs. in-hospital removal) is controversial If the patient’s airway cannot be

adequately accessed or secured, or if the helmet hinders emergency care procedures, the helmet should be removed in the field