musculoskeletal trauma
DESCRIPTION
Musculoskeletal Trauma. EMS Professions Temple College. Incidence/Mortality/Morbidity. 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 - PowerPoint PPT PresentationTRANSCRIPT
Musculoskeletal Musculoskeletal TraumaTrauma
EMS ProfessionsTemple College
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
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
Prevention StrategiesPrevention Strategies
Sports Training Seat Belt use Child Safety Seat use Airbag use Gun Safety and Education Motorcycle education and
protective equipment Fall prevention Can you think of others?
Musculoskeletal System Musculoskeletal System FunctionFunction
Scaffolding/SupportProtection of vital organsLocomotionProduction of RBCStorage of minerals
Musculoskeletal Musculoskeletal StructuresStructures
SkinMusclesBonesTendonsLigamentsCartilage
Musculoskeletal Musculoskeletal Structures - Structures - SkinSkin Holds all structures together
Barrier function Protects underlying structures Subcutaneous tissue
– Fat– Fascia
Further discussion in Soft-Tissue Trauma
Musculoskeletal Musculoskeletal Structures -Structures -MuscleMuscle Composed of specialized cells with
ability to contract Voluntary (Skeletal)
– Conscious control– Allows mobility
Smooth (Bronchi, GI tract, blood vessels)– Controlled by ANS– Able to alter inner lumen diameter
Cardiac– Contracts rhythmically on its own
Musculoskeletal Musculoskeletal Structures -Structures -MuscleMuscle Can only contract
Skeletal muscle causes movement by shortening resulting in pulling on bones through cord like bands
Musculoskeletal Musculoskeletal StructuresStructures
Tendons– Bands of connective tissue binding
muscles to bones Cartilage
– Connective tissue covering the epiphysis
– Surface for articulation Ligaments
– Connective tissue supporting joints– Attach bone ends to each other
BonesBones
Living tissue Consists of cells which deposit
calcium, phosphorus on protein matrix
Constantly remodels itselfAble to repair damage without
formation of scar tissue
BonesBones
Structural form for body Protection Point of attachment for tendons,
ligaments, cartilage and muscles Allows for movement Storage of minerals Produce red blood cells
Skeletal System Skeletal System ComponentsComponents
Axial Skeleton– forms the central axis of the body– includes skull, vertebral column, bony thorax
Appendicular Skeleton– limbs
Pectoral girdle– bones that attach the upper limbs to the
axial skeleton Pelvic girdle
– paired bones of the pelvis that attach the lower limbs to the axial skeleton and sacrum
Long Bone AnatomyLong Bone Anatomy
Diaphysis– Long, narrow shaft– Dense, compact bone
Metaphysis– Head of bone– Between epiphysis and diaphysis
Medullary canal– Contains marrow
Long Bone AnatomyLong Bone Anatomy
Periosteum– Outer fibrous covering– Allows for increase in diameter– Vascular– Nerves
Epiphysis– Articulated, widened end– Allows bone to lengthen– Cancellous bone with red blood marrow– Weakest point in child’s bone
JointsJoints
Points of articulation between bones
Fused/Fibrous– Sutures
» Between bones of skull
Synovial– Fluid filled chamber which lubricates
articulated surfaces– Allow for movement
» gliding, flexion, extension, abduction, adduction, circumduction, rotation
Synovial JointsSynovial Joints
Ball/Socket–Shoulder/Hip
Hinge–Elbow/Knees/Fingers/TMJ
Pivot–Between radius and ulna
Gliding–Bones of wrist
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
Mechanism of InjuryMechanism of Injury
Direct – Break occurs at point of impact
Indirect– Force is transmitted along bone– Injury occurs at some point distant to
point of impact– Femur, hip, pelvic fracture due to
knees hitting dash
Mechanism of InjuryMechanism of Injury
Twisting– Distal limb remains fixed– Proximal part rotates– Shearing, fracturing occur– Football. skiing accidents
Avulsion– Muscle and tendon unit with attached
fragment of bone ripped off bone shaft
Mechanism of InjuryMechanism of Injury
Stress– Occur in feet secondary to prolonged
running or walking Pathological
– Result of Fx with minimal force– Cancer, osteoporosis
Fracture DescriptionsFracture Descriptions
Open vs Closed X-Ray descriptions
– greenstick– oblique– transverse– comminuted– spiral– impacted– epiphyseal
Fracture TypesFracture Types
Transverse– Cuts shaft at right angle to long axis– Often caused by direct injury
Greenstick– Pliable bone splinters on one side
without complete break– Occurs in children
Fracture TypesFracture Types
Spiral– Fx site coils through bone like spring– Occurs with torsion
Oblique– Occurs at angle to long axis of shaft
Comminuted– Bone broken into 3 or more pieces
Fracture TypeFracture Type
Impacted – Bone ends jammed together– Occurs with compression– Frequently no loss of function
Problems Associated with Problems Associated with Musculoskeletal InjuriesMusculoskeletal Injuries
Hemorrhage Interruption of Blood Supply Disability Instability Soft Tissue injury
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
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)
Sprains/StrainsSprains/Strains
Sprain– tearing of ligaments surrounding joint
Strain– overstretching of muscle or tendon
Musculoskeletal Musculoskeletal AssessmentAssessment
The possibilities– Life-threatening injuries or conditions,
including life/limb threatening musculoskeletal trauma
– Life/Limb threatening injuries and only simple musculoskeletal trauma
– Life/Limb threatening musculoskeletal trauma and no other life/limb threatening injuries
– Only isolated, non-life/limb threatening injuries
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
Musculoskeletal Musculoskeletal AssessmentAssessment
With few exceptions orthopedic injuries are not life
threatening. Do not let drama of obvious or
grossly deformed fracture distract you from more serious
problems involving ABC’s
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
Musculoskeletal Musculoskeletal Assessment Assessment
Vascular injury should be suspected in all Fx’s/dislocations UPO
Evaluate with 5 P’s– Pain– Pallor– Pulselessness– Paresthesias– Paralysis
Musculoskeletal Musculoskeletal AssessmentAssessment
History of Present Injury– Where is pain felt?– What occurred? What position was
limb in?– Were deceleration forces involved?– Was there direct impact?– Has there ever been previous trauma
or Fx?
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
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.
Musculoskeletal Musculoskeletal AssessmentAssessment
Palpation and Inspection – Exposed bones
» Fx can be open without exposed bones
– Principal danger is not to bones, but to underlying neurovascular structures around bone.
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!
Musculoskeletal Musculoskeletal AssessmentAssessment
Because orthopedic injuries have low priority in multiple systems trauma, all Fx’s may not be found in field
Long Board– Splints every bone and joint– No loss of time– Focus on critical conditions
Key PointKey Point
Orthopedic injuries are seldom immediately life threatening.
Tend to other issues first. Only immediately life threatening
orthopedic injury is Pelvic Fx due to potential massive hemorrhage
Key PointKey Point
The problem is not the damage to the bone
The problem is the damage the bone does to the
surrounding soft tissues.
Evaluate Neurovascular Function Distally
Management - GeneralManagement - General
Immobilization Objectives– Prevent further damage to
nerves/blood vessels– Decrease bleeding, edema– Avoid creating an open Fx– Decrease pain– Early immobilization of long bone
fractures critical in preventing fat embolism
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
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
Management - GeneralManagement - General
Pain Management– Avoid pain management until
head/thoracic injury is ruled out– Appropriate for isolated
musculoskeletal injuries (fracture/sprain/dislocation)
– Underutilized– Morphine sulfate titrated to pain
relief without compromising adequate BP and ventilations
Management - PediatricManagement - Pediatric
Green stick Fx may go unrecognized
Fx can occur in epiphyseal plate, early closure can prevent further growth of affected bone
If no explanation from patient or parents or injury does not follow mechanism, suspect child abuse.
Oversight of volume loss when evaluating pt with multiple
Fx’sEstimate blood loss at each Fx
site
Evaluation of neurovascular deficiencies in distal extremity
Management ErrorManagement Error
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
DislocationsDislocations
Nerves, blood vessels pass very close to bone. Pressure on these structures can occur
Checking distally essential– Pulse presence– Pulse strength– Sensation
Management - Management - DislocationsDislocations
Principles of fracture/dislocation management– Usually splinted in position of injury– Neurovascular assessment before, after
splinting– Attempt realignment of dislocations if
» distal circulation is impaired» long transport
– Discontinue realignment if pain increased significantly or resistance is encountered
– Immobilize proximal. distal joints and bones
– Analgesia, possible cold application
SprainsSprains
Stretching. tearing of ligaments surrounding joint
Occur when joint is twisted beyond normal range of motion
Most common = Ankle
Sprain ManagementSprain Management
Characteristics– Pain– Tenderness– Swelling– Discoloration
Typically does not manifest deformity Ice, compression, elevation,
immobilize When in doubt, splint Consider analgesia
StrainsStrains
Tearing, stretching of musculotendonous unit.
Spasm, pain on active movement Usually no deformity, swelling Pain present on active movement Avoid active movement, weight
bearing
Minor Musculoskeletal Minor Musculoskeletal Injury ManagementInjury Management
Cold/Heat application– cold best if in first 48 hours to reduce
swelling– heat best if after 48 hours to increase
circulation– no direct application to soft tissue
» wrap in towel or gauze
Minor Musculoskeletal Minor Musculoskeletal Injury ManagementInjury Management
Other care– Is immobilization/splinting needed?– Is an X-ray needed?– Is there a need for MD follow? ED
visit?– What type of transport is needed?
Traumatic AmputationTraumatic Amputation
First priority - ABC’s– Bleeding from stump usually not a
problem Next priority is to save limb
Traumatic Amputation Traumatic Amputation ManagementManagement
Control Bleeding Elevate Apply direct pressure to stump Avoid tourniquet except as last
resort
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
Upper Extremity FxUpper Extremity Fx
Proximal Humerus– Usually from a fall on outstretched
hand. – Manage with sling, swathe– Deltoid bulge often accentuated
Shaft of Humerus– Usually obvious due to deformity– Wrist drop may occur– Vascular compromise may be present
Upper Extremity FxUpper Extremity Fx
Colles Fx (silver fork)– Distal radius– Usually secondary to fall on
outstretched hand– Common in children
Shoulder DislocationShoulder Dislocation
Realignment– One attempt if neurovascular
compromise– Do not attempt if associated with
other severe injuries or spine injuries– Provide analgesia– Pull into anatomical position
Splinting– Be creative– Sling, swathe if possible– Cravats are our friends!
Hip DislocationHip Dislocation
Anterior– Blow to abducted leg, external
rotation of affected extremity Posterior
– Blow to flexed/Abducted knee– More severe than anterior dislocation– Associated with rupture of joint
capsule, acetabular Fx, sciatic nerve injury
Management - Hip Management - Hip DislocationDislocation Realignment
– One attempt if severe neurovascular compromise
– Do not attempt if associated with other severe injuries
– Provide analgesia– Steady and slow pull along shaft of femur– If successful, “pops” into joint, sudden
relief of pain, leg can easily return to extension
Immobilization– Flexion of hip/knee for comfort acceptable
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)
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
Femur FxFemur Fx
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
Femur FxFemur Fx
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
Femur Fx - ManagementFemur Fx - Management
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
Femur Fx - ManagementFemur Fx - Management
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)
– What if time (patient instability) does not allow for traction splint application?
Lower Extremity FxLower Extremity Fx
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
Management - Lower Management - Lower Extremity FxExtremity Fx
Patellar, Tibia/Fibula, and Calcaneal– Assess for neurovascular impairment– Realign long bones– Splinting possibilities
» board splint or cardboard splint» vacuum splint» pillow
Elbow DislocationElbow Dislocation
Presentation– High neurovascular traffic– Volkmann’s contracture - ischemia
secondary to trauma causes ischemic contractions
Management– assess for neurovascular impairment– sling– swathe– analgesia and position of comfort
Knee DislocationKnee Dislocation
Presentation– Trauma to popliteal artery– Many reduce spontaneously– Knee dislocation has a 50% incidence
of associated vascular injury– Presence of distal pulse does not rule
out vascular injury
Management - Knee Management - Knee DislocationDislocation
Management– Assess for neurovascular impairment– One attempt at realignment if
impairment or delayed transport– Do not realign if associated with other
severe injuries– analgesia and position of comfort– gentle, steady traction to move into
normal position» success by “pop” into joint, less deformity
and pain, and increased mobility
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
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