muscle skeletal

Musculoskeletal Musculoskeletal TraumaTrauma

SSgt Jeffery C. PintlerWashington Air National

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Incidence/Mortality/Incidence/Mortality/MorbidityMorbidity

Occur in 70-80% of all multi-trauma patients

Blunt or Penetrating Upper extremity rarely life-

threatening– may result in long-term impairment

Lower extremity associated with more severe injuries– possibility of significant blood loss– femur, pelvic injuries may pose life-

threat

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Incidence/Mortality/Incidence/Mortality/MorbidityMorbidity

Problem is not just the bone injury– Other injuries caused by the injured

bone» Soft tissue» Vascular» Nervous system» Decreased function

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Musculoskeletal System Musculoskeletal System FunctionFunction

Scaffolding/SupportProtection of vital organsMovementProduction of Red Blood CellsStorage of minerals

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Musculoskeletal Musculoskeletal StructuresStructures

SkinMusclesBonesTendonsLigamentsCartilage

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Muscular SystemMuscular System

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Skeletal SystemSkeletal System

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Musculoskeletal Musculoskeletal Structures - Structures - SkinSkin Holds all structures together

Barrier function Protects underlying structures Subcutaneous tissue

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Musculoskeletal Musculoskeletal Structures -Structures -MuscleMuscle Three types of muscle cells

Voluntary (Skeletal)– Conscious control

Smooth (Bronchi, GI tract, blood vessels)– Unconscious control

Cardiac– Contracts rhythmically on its own

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Musculoskeletal Musculoskeletal StructuresStructures

Tendons– Bands of connective tissue binding

muscles to bones Cartilage

– Connective tissue covering the ends of bones

– Needed for joint movement Ligaments

– Connective tissue supporting joints– Attach bone ends to each other

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Types of JointsTypes of Joints

Ball/Socket–Shoulder/Hip

Hinge–Elbow/Knees/Fingers/TMJ

Pivot–Between radius and ulna

Gliding–Bones of wrist

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FractureFracture

Break in continuity of bone Closed

– Overlying skin intact Open

– Wound extends from body surface to fracture site

– Produced either by bones or object that caused Fx

– Danger of infection– Bone end not necessarily visible

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Common fracturesCommon fractures

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Fracture DescriptionsFracture Descriptions

Open vs Closed X-Ray descriptions

– greenstick– oblique– transverse– comminuted– spiral– impacted– epiphyseal

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Complications associated Complications associated with Fractureswith Fractures

Hemorrhage– Possible loss within first 2 hours

» Tib/Fib - 500 ml» Femur - 500 ml» Pelvis - 2000 ml

Interruption of Blood Supply– Compression on artery

» decreased distal pulse

– Decreased venous return

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Complications associated Complications associated with Fractureswith Fractures

Disability– Diminished sensory or motor function

» inadequate perfusion» direct nerve injury

Specific Injuries– Dislocation– Amputation/Avulsion– Crush Injury (soft tissue trauma

discussion)

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Musculoskeletal Musculoskeletal AssessmentAssessment

Initial Assessment– ABCDs– Life threats managed first– Don’t overlook life/limb threatening

musculoskeletal trauma– Don’t be distracted by “gross” but

non-life/limb threatening musculoskeletal injury

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Musculoskeletal Musculoskeletal AssessmentAssessment

The six “P”s of musculoskeletal assessment– Pain

» on palpation» on movement» constant

– Pallor - pale skin or poor cap refill– Paresthesia - “pins and needles”

sensation– Pulses - diminished or absent– Paralysis– Pressure

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Musculoskeletal Musculoskeletal AssessmentAssessment

Palpation and Inspection– Swelling/Ecchymosis

» Hemorrhage/Fluid at site of trauma

– Deformity/Shortening of limb» Compare to other extremity if norm is

questioned

– Guarding/Disability» Presence of movement does not rule out

fracture

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Musculoskeletal Musculoskeletal AssessmentAssessment

Palpation and Inspection– Tenderness

» Use two point fixation of limb with palpation with other hand.

» Tenderness tends to localize over injury site.

– Crepitus» Grating sensation » Produced by bones rubbing against each

other. » Do not attempt to elicit.

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Musculoskeletal Musculoskeletal AssessmentAssessment

Palpation and Inspection– Distal to injury, assess:

» skin color » skin temperature» sensation» motor function

– If uncertain, compare extremities– When in doubt splint!

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Musculoskeletal Musculoskeletal AssessmentAssessment

Initial Assessment– ABCDs– Life threats managed first– Don’t overlook life/limb threatening

musculoskeletal trauma– Don’t be distracted by “gross” but

non-life/limb threatening musculoskeletal injury

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Management - GeneralManagement - General

Immobilization Objectives– Prevent further damage to

nerves/blood vessels– Decrease bleeding, edema– Avoid creating an open Fracture– Decrease pain– Early immobilization of long bone

fractures critical in preventing fat embolism

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Management - GeneralManagement - General

Principles of Fracture Management– Splint joint above, below– Splint bone ends– Loosely cover open fracture sites– Neurovascular assessment

» before and after splinting

– Gentle in-line traction of long bone » maintain normal alignment if possible» reduction of angulated fracture site

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Management - GeneralManagement - General Principles of Fracture Management

(cont)– Position of function– Pain management

Body Splinting – In urgent patient, entire body is stabilized by

using a long board– Lower extremity fractures can be splinted as

one to the long board Long Board

– Splints every bone and joint– No loss of time– Focus on critical conditions

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DislocationsDislocations

Displacement of bone end from articulating surface at joint

Pain or pressure is most common symptom

Principal sign is deformity May experience loss of motion of

joint

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DislocationsDislocations

Nerves, blood vessels pass very close to bone. Pressure on these structures can occur

Checking distally essential– Pulse presence– Pulse strength– Sensation

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SprainsSprains

Stretching. tearing of ligaments surrounding joint

Occur when joint is twisted beyond normal range of motion

Most common = Ankle

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Sprain ManagementSprain Management

Characteristics– Pain– Tenderness– Swelling– Discoloration

Typically does not manifest deformity Ice, compression, elevation,

immobilize When in doubt, splint Consider analgesia

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StrainsStrains

Tearing, stretching of musculo/tendonous unit.

Spasm, pain on active movement Usually no deformity, swelling Pain present on active movement Avoid active movement, weight

bearing

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Traumatic AmputationTraumatic Amputation

First priority - ABC’s– Bleeding from stump usually not a

problem Next priority is to save limb

Traumatic Amputation ManagementTraumatic Amputation Management

•Control Bleeding•Elevate•Apply direct pressure to stump•Avoid tourniquet except as last resort

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Tourniquet applied to an Tourniquet applied to an arm amputationarm amputation

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Tourniquet applied to a Tourniquet applied to a leg amputationleg amputation

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Traumatic Amputation - Traumatic Amputation - Limb ManagementLimb Management

Place in saline moist gauze Place in plastic bag Place bag on ice Do not

– Warm amputated part– Place part in water– Place directly on ice– Use dry ice

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Sling and swathes applied Sling and swathes applied to humerus fractureto humerus fracture

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Applying a cravat slingApplying a cravat sling

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Splint applied to a Splint applied to a fractured elbowfractured elbow

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Swathes applied to a Swathes applied to a fractured elbowfractured elbow

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Splint applied to a Splint applied to a fractured forearmfractured forearm

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Sling and swath applied to Sling and swath applied to a fractured forearma fractured forearm

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Splint applied to a Splint applied to a fractured wristfractured wrist

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Improvised jacket slingImprovised jacket sling

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Pelvic FracturePelvic Fracture

Direct or indirect force Pelvic ring tends to break in two

places Bone fragments can cause damage

– Major vessels– Urinary bladder– Rectum resulting in contamination– Nerves (Lumbrosacral plexus or sciatic)

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Pelvic Fx ManagementPelvic Fx Management

Treat as potential critical trauma patient

Comfortable position if possible Splint = Minimize movement

– Scoop stretcher– Body to long board– MAST for splint

Replace volume prn– Possible 4000cc blood loss– 2 IV of LR

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Military Anti-Shock Military Anti-Shock TrousersTrousersPneumatic Anti-Shock Pneumatic Anti-Shock GarmentGarment

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Femur FractureFemur Fracture

Femoral Neck (Hip)– Most common in mid to late 60’s age

group.– Leg tends to rotate outward

» looks like anterior hip dislocation

– Minimal blood loss tends to occur due to joint capsule

Management– NO traction splint– long board, scoop or MAST

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Femur FractureFemur Fracture

Mid-Shaft– Result from torsion in very young or

old– High speed deceleration with impact

» Hypovolemic shock» Fat Embolism

– Early immobilization with traction splint will help prevent

– 1000 to 2000 cc blood loss

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Femur Fracture - Femur Fracture - ManagementManagement

Assess for traction splint contraindications

May use PASG, secure to long board– Secure to opposite extremity and then

to long board (premise for the Sager splint)

Assess for :– Soft tissue, vascular, or nerve injury– Assess for hypovolemia

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Femur Fracture - Femur Fracture - ManagementManagement

Traction Splints– Used on mid-shaft femur fractures– Do not use if suspected fracture

involves» proximal or distal 1/3 of femur» pelvis» hip (or hip dislocation)» knee (or knee dislocation)» ankle (or ankle dislocation)

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Lower Extremity FractureLower Extremity Fracture

Patellar– Due to direct impact

Tibia/Fibula– High potential for:

» Open fracture» Hemorrhage» Infection

Calcaneal– Results from falls (foot landing)– High incidence of lumbar sacral

compression

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Management - Lower Management - Lower Extremity FractureExtremity Fracture

Patellar, Tibia/Fibula, and Calcaneal– Assess for neurovascular impairment– Realign long bones– Splinting possibilities

» board splint or cardboard splint» vacuum splint» pillow

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Splint applied to an upper Splint applied to an upper leg fractureleg fracture

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Splint applied to a Splint applied to a fractured kneefractured knee

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Uninjured leg used as a Uninjured leg used as a splintsplint

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Hemorrhage ManagementHemorrhage Management

Direct Pressure– Most effective method– Pressure bandage

Elevation– Combination with direct pressure

Pressure Point– Brachial, Femoral, Carotid

Tourniquet– last resort– rarely required

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Applying and securing a Applying and securing a field dressingfield dressing

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Applying manual pressureApplying manual pressure

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Pressure points for control Pressure points for control of arterial bleedingof arterial bleeding

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TourniquetTourniquet

Last resort, but do not wait too long.

Use flat wide material BP cuff Close to the wound as possible Do not remove Leave in plain view Note time applied and clearly

communicate during transfer of care

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Application of a tourniquet Application of a tourniquet to stop bleedingto stop bleeding

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ReferencesReferences

Field Manual 8-230 U.S. Army 2003 Combat Lifesaver Instructor

Manual U.S. Army 2003

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