1. Musculoskeletal Injuries
June/July 2013 CE
Condell Medical Center
EMS System
Site Code: E-1213
Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives
Upon successful completion of this program the EMS provider will be able to:
Describe anatomy and physiology of the musculoskeletal system.
Discuss the effects of aging on the musculoskeletal system.
Describe the pathophysiology of strains, sprains, dislocation, and fractures.

3. Objectives cont’d
Describe the assessment of the musculoskeletal system.
Discuss interventions and management of musculoskeletal system injuries.
Discuss pain management based on the Region X SOP’s.

4. Objectives cont’d
Describe compartment syndrome, presentation, and intervention in the field.
Actively participate in case scenario discussion.
Actively participate in application of a variety of immobilization devices including the HARE traction splint or Sager and KED device.
Successfully complete the post quiz with a score of 80% or better.

5. Musculoskeletal Injuries
Common group of injuries
Many injuries are isolated
Few are life threatening
Many can affect quality of life if just temporarily

6. Function of Musculoskeletal System
Gives body its shape
Protects internal organs
Can also cause injuries to those same organs
Allows for movement
Usually performed by muscles
Storage system for salts and minerals used in the body
Produces red blood cells used for oxygen transport

7. Control of Musculoskeletal System
Under control of the brain and nervous system
Skeletal muscle is voluntary muscle
Can be contracted and relaxed at the will of the individual
Walking, sitting
Swallowing, smiling
Talking
Performing activities of daily living

8. A & P Musculoskeletal System
A bony framework making up the skeleton
System held together by ligaments
Ligaments connect bone to bone
System held together by layers of muscles
Tendons connect muscles to bones
Skeletal muscles are voluntary
Includes additional connective tissue
Example: cartilage

9. Joints May be movable or immovable Movement direction includes Flexion
Extension
Abduction
Adduction
Pronation
Supination
Flexion – bending or a decrease in the angle between bones and body parts
Extension – straightening or o=increasing the angel between bones and body parts
Abduction – moving away from the midline (think of abduction of a child as taking something away)
Adduction – moving toward the midline (opposite of abduction)
Pronation – turning the forearm so palm in turned toward or facing the back
Supination – turning the forearm so the palm faces the front

10. Pathological Fractures
Fractures resulting from a disease that causes degeneration and weakening of a bone making it prone to fracture
Fracture often occurs with little provocation; minimal force
Often occurs in the presence of a diagnosis of cancer

11. Effects of Aging Decreased flexibility Decreased range of motion
Loss of balance
Osteopenia – loss of bone mineral density; softening of bones
Osteoporosis – degenerative bone disorder with loss of bone density making bones brittle and fragile
Weakened bones more susceptible to fracturing
More common in women than men but affects both populations

12. Counteracting the Effects of Aging
Stay active
Strengthen your core
Helps with balance
Continue weight bearing exercises
Cardiovascular exercise strengthens your heart
Strength training builds bone and muscle strength

13. Mechanism of Injury
Determining mechanism of injury can help determine area of injury and may point to the extent of injury suffered
Forces divided based on MOI
Direct – a direct blow
i.e.: knees hit dashboard in MVC injuring the knee
Indirect – force impacts one end of limb and damage transmitted to a distant point
i.e.: fall on outstretched arm resulting in fractures of the wrist and clavicle
Twisting – one part of extremity stationary while the rest twists
i.e.: sliding on ice, at end of ice patch the foot stops but the body remains in motion and rolls over the foot

14. Can you tell what the injury is???
No, not always without more diagnostics
Most musculoskeletal injuries are treated the same regardless of the final diagnosis
So…
Why do you need to know the difference between a sprain and a dislocation or fracture???
Because…
As a professional, you should be able to use critical thinking skills
You might be able to fine tune treatment based on mechanism of injury and your impression

15. Strains Injury to a muscle or muscle and tendon
Often caused by overextension or over stretching
Muscle fibers tear
Pain is typical to that experienced from over muscle use
Often no swelling or discoloration because there is no bleeding

16. Sprains
Injury to the joint capsule with damage to or tearing of the connective tissue
Usually involves ligaments
Most vulnerable are shoulder, knee and ankle joints
Typically immediate pain and tenderness followed by swelling and eventually discoloration
Can be more swollen and more painful than some fractures

17. Dislocations Significant injury
Displacement of bone from its normal position in a joint
Joint usually forced beyond normal range of motion
Can cause damage to blood vessels and nerves by compression or tearing
Need treatment sooner than later

18. Dislocation Typical appearance
Joint found in abnormal appearance with deformity and possible swelling
Pain and tenderness present
Inability to move extremity
Not recommended to manipulate dislocations but to splint in position found
Loss of distal pulses increases the severity of the injury

19. Fractures Loss of continuity of the structure of a bone
Sharp fragments may injure surrounding tissue
Arteries and bones run throughout the bones
Vessels within the bone may tear or rupture and bleed

20. Fractures cont’d Classified as open or closed
Open is associated with an open wound to the skin
The wound may be from the outside inward (i.e.: the mechanism of injury from a missile) or from the bone end poking through skin
Displaced bones more likely to damage surrounding nerves, blood vessels, muscles, ligaments, and tendons

21. Critical Fractures Femur and pelvis Potential blood loss
Potential for significant blood loss and development of hypovolemic shock
Goal – immobilize bony injury AND reduce potential blood loss
Bones tend to bleed when injured AND exposed bone ends could lacerate near by vessels
Potential blood loss
Each femur – 1500 ml blood loss
Pelvic fracture – 2000 ml blood loss

22. Critical Conditions Pulselessness or cyanosis
Immobilize extremity
Provide expedited transport
Note: Limb threatening musculoskeletal injuries take a back seat to life threatening injuries
If there is no time to immobilize an orthopedic injury, placing the patient on a backboard allows some immobilization

23. Absence of Distal Pulses
Check capillary refill, skin temperature/color and general condition
If pulses found, mark site with an “x” to help find the same pulse site on reassessment
Continue to check for sensation and movement
Provide rapid transport
Splint extremity in position found
Document assessment and care provided

24. General Patient Presentation
Common presentations of most musculoskeletal injuries
Pain
Swelling
Decreased or lack of movement
Inability to bear weight
Possible deformity
Occasionally blood loss (i.e.: femur, pelvis

25. Assessment of Musculoskeletal System
Assessment before and after splinting
Assess pulses (can compare to opposite side)
Evaluate motor capability
Can you wiggle fingers/toes
Evaluate sensory status
Can you feel me touching fingers/toes?
Call it what you want:
PMS – CMS - SMV
PMS – pulse, motor, sensory
CMS – circulation (i.e.: pulse), motor, sensory
SMV – sensory, motor, vascular (i.e.: pulses)

26. Management of Musculoskeletal Injuries
RICE
Rest
Ice application to reduce swelling
Compression with ACE wrap to reduce swelling
Elevation to reduce swelling
Reducing swelling reduces the pain level
Pain control with medication
Distraction

27. Region X Pain Management
Same formula for adults and peds
Fentanyl 0.5 mcg/kg IVP/IN/IO
May repeat same dose in 5 minutes
Max total dose 200 mcg

28. Fentanyl Synthetic opioid narcotic Used for analgesic purposes
Properties similar to morphine with less cardiovascular side effects
Administer over 2 minutes IVP/IN/IO
Watch for respiratory depression, bradycardia

29. Fentanyl cont’d Onset - immediate Peak effect – 3 – 5 minutes
Duration minutes
IN route used in absence of IV access
Administer in divided doses
IN route onset 2 minutes

30. Narcan® (Naloxone) Narcotic antagonist
Competes for opiate receptor sites in brain
Reverses effects of narcotics including synthetics
Onset within 2 minutes
Dosing- enough to improve ventilations
Adults 2 mg IVP/IN/IO
Peds > 20 kg – 2 mg
Peds < 20 kg – 0.1 mg/kg

31. Narcan cont’d Side effects are rare BUT
Can cause narcotic withdrawal in narcotic dependent person
May present with seizures after administration
Effects may not last as long as the narcotic you are countering
Watch for relapse of level of consciousness and respiratory effort

32. Compartment Syndrome
Complication usually associated with closed injuries to extremities
Major muscle groups contained in compartments surrounded by inelastic, non-expanding fascia
Pressures usually around 0
Pressures over 30 mmHg can restrict capillary blood flow
Irreversible ischemic damage usually occurs at about 10 hours

33. Compartments of the Leg

34. Compartment Syndrome
There is excessive swelling in an enclosed space and that space has expanded to full capacity with no more room to expand
Skin can only be stretched so far
High pressures impede blood flow and leads to hypoxia of tissues
Hypoxic tissues trigger leakiness of capillaries causing further swelling

35. Compartment Syndrome Assessment
Develops over time most likely after 6-8 hours
Not usually seen in the field immediately after the insult
History in recent past of an injury
Prevalent symptom – pain out of proportion; pain with passive stretching
Typically a deep, burning pain
Pain not affected by positioning
Motor and sensory usually normal
Distal pulses usually present

36. Compartment Syndrome Intervention
In the field, care for the underlying injury
Splint and immobilize all potential fractures
Apply cold packs as needed
Elevate injured extremity
Reduces edema
Increases venous return
Lowers compartment pressure
Note: Care may differ in the hospital; limited resources available in the field

37. Immobilization Devices
Goal – to prevent further injury that could be caused by movement
Reduces stress on ligaments, muscles, and tendons
Reduces pain by reducing limb motion

38. Golden Rule of Immobilization
Immobilize the joint above and the joint below the injury
When applying a splint that wraps an extremity, wrap from a distal to more proximal point
This prevents trapping of blood distal to the injury
Don’t wrap so tight as to impede blood flow
Evaluate distal circulation, motor function, and sensation before and after splinting
Document findings

39. Traction Splints
Proximal femur fractures (surgical neck and intertrochanteric fractures) frequently caused by hip injuries, transmitted forces, or aging
Referred to as hip fractures
Do not benefit from traction splints
If a joint injury is suspected, traction splints should not be used

40. Traction Splints Purpose Note: Relieve the spasm
Relieving spasm decreases the pain
Note:
Rapid transport for life threatening condition takes priority over placing splints on a patient
Immobilization using a full backboard may be the best you can do in those situations

41. HARE Traction
For suspected mid-shaft femur fractures

42. HARE Traction Steps 1 rescuer maintains manual traction to foot
2nd rescuer assesses distal CMS/PMS/SMV
2nd rescuer prepares traction device
Place device next to uninjured leg
Place pad at ischial crest
Adjust length to extend past foot
Tighten locking collars

43. HARE Traction Steps cont’d
Open & position velcro straps
Open ratchet & extend traction strap
Place splint next to injured leg
2nd rescuer applies ankle hitch & takes over applying firm, gentle manual traction via ankle hitch
1st rescuer moves splint into position firmly against ischial tuberosity

44. Ischial Tuberosity Most distal part of the bony pelvis
The shape forms the platform for sitting when upright
Structured to support the body’s weight when sitting

45. HARE Traction Steps cont’d
1st rescuer secures proximal, pubic strap high over the thigh
1st rescuer attaches ankle hitch to traction splint
Traction strap tightened until pain & spasm are relieved and stopped when leg lengths are equal
Manual traction stops when mechanical traction takes over and is effective

46. HARE Traction Steps cont’d
Remaining straps secured in place
Avoid placing a strap across injury site and knee
Support distal traction stand on backboard
Backboard most likely will need to be shifted towards foot end of cot and extend off of cot to support traction stand
Reassess distal CMS/PMS/SMV after splinting
Document assessment findings and procedure

47. Sager Splint
Alternative device for suspected femur fractures

48. Sager Splint cont’d
Place splint between patient’s legs along medial aspect of injured leg with pulley towards the injured leg
Snuggly wrap the ankles with the ankle harness provided
Pull control tabs to engage ankle harness tightly against crossbar
Grasp the padded shaft of splint with one hand and red traction handle with the other

49. Sager Splint cont’d
Gently extend the inner shaft until desired traction is achieved
Suggested is 10% of patient weight up to 7kg (15#) per leg for unilateral fractures (14 kg (30#) bilateral fractures)
Apply remaining straps for a snug fit
Apply figure 8 straps around feet to prevent rotation
Recheck distal CMS/SMV/PMS

50. KED Device When extrication does not need to be emergent
It takes time and resources to apply

51. KED Device cont’d KED slid into position behind the patient
Manual head immobilization maintained
Middle torso strap applied
Bottom torso strap secured
Leg straps are secured
Can be criss-crossed or fastened to same side
Avoid criss-cross if groin injury present
Now pad void between head and device and secure head

52. KED Device cont’d Just prior to moving, top torso strap is secured
Not done earlier to prevent restriction or interference of breathing
Note:
Secure torso prior to securing the head
Secure the forehead strap running strap in a downward direction
Secure the chin strap over the cervical collar

53. KED Device

54. KED Device
To remove patient from vehicle, grasp the side handles to pivot/tilt/lift the patient
Grasp the side handles and under the patient’s knees to raise them enough to slide a backboard under them
Once patient is extricated and on cot, loosen top strap to allow for chest expansion
Loosen groin strap for legs to straighten
Readjust remaining straps as necessary for transport

55. KED Device Lightly scrub to remove gross contaminant after each use
Disinfect after each use
Allow to air dry prior to placing in the storage bag

56. Case Scenario Review Review the following cases
Determine your general impression
Determine your treatment approach based on presentation and signs and symptoms
Discuss methods to reduce pain

57. Case Scenario #1
Your patient is an 89 year-old female who fell onto an outstretched hand
You note deformity to the wrist
VS: B/P 140/92; P – 92; R – 18
Pain 6/10

58. Case Scenario #1
What is important to ask this patient with regards to her injury?
For any patient who fell, important to ask WHY they fell
If patient was dizzy, consider a cardiac problem until proven otherwise
Document reason for the fall

59. Case Scenario #1 Patient has a wrist injury from a fall
Based on mechanism of injury (MOI), what else should be assessed?
Evaluate up the extremity to points distal to the injured site
Upper extremity – evaluate fingers to shoulder including clavicle
Lower extremity – evaluate toes to hip

60. Case Scenario #1 What is standard assessment for orthopedic injuries?
Evaluate distal CMS/PMS/SMV before and after splinting
What is standard treatment for orthopedic injuries?
RICE
Rest - immobilize
Ice – not directly applied over site
Compression – wrap with an ACE
Elevate - higher than heart for swelling

61. Case Scenario #1 How would you address this patient’s pain? RICE
Rest, ice, compress, elevate
Fentanyl 0.5 mcg/kg IVP/IN/IO
Can repeat same dose in 5 minutes if needed
Max total dosing is 200 mcg
Watch for respiratory depression with this synthetic narcotic

62. Case Scenario #2
You respond to a sports complex for a 17 year-old injured
They planted their foot and then rolled/twisted their leg
There is obvious deformity to the ankle/foot
VS: B/P 118/70; P – 82; R – 18
Pain 9/10

63. Case Scenario #2 - MOI

64. Case Scenario #2 What would be your initial assessment?
MOI
Appearance
Distal CMC/SMV/PMS before and after splinting
Level of pain
What is your treatment?
RICE
Immobilize in position found

65. Case Scenario #2 How would you address the pain in this 17 year-old?
RICE is used
Follow Peds Pain Management SOP
Same as the adult SOP
Fentanyl 0.5 mcg/kg IVP/IN/IO
May repeat same dose in 5 minutes is needed
Max total doses is 200 mcg
Watch for respiratory depression

66. Case Scenario #2
17 year-old patient states he does not want to be transported
What would you do?
As a minor, this patient cannot give medical direction or sign a release
Contact the parents
If unable to contact the parents, transport the patient to the closest appropriate facility
Provide explanation to the patient why you must transport

67. Case Scenario #3
25 year-old male fell off a ladder while cleaning gutters
The patient is unconscious
GCS 2/2/4 (total 8)
There is obvious deformity of the right femur as you approach
The patient has multiple abrasions and contusions
There is blood draining from one ear

68. Case Scenario #3 VS: B/P 110/70; P – 88; R 16 What is your impression?
Multiple trauma
Head injury with orthopedic injuries
VS indicate increasing intracranial pressure
What category trauma is this?
Category I
Transport to highest level trauma center within 25 minutes

69. Case Scenario #3
Would you take the time to apply a HARE or Sager to this injury?
No, life threats are treated over limb threats
Placing a patient on the backboard will need to serve as a splint
HARE or Sager splints can be applied later as there is time and resources

70. Case Scenario #3
You are unable to start a peripheral IV on this patient
What would you do?
Place an IO
As fluid is infusing, the patient becomes agitated and tries to reach for the IO site
Administer Lidocaine via the IO for pain control
Think
Lidocaine 50 mg over 1 minute and wait 1 minute to resume infusion

71. Case Scenario #4 Your 45 year-old patient injured their knee falling
VS: B/P 128/86; P – 86; R – 16
Pain 5/10

72. Case Scenario #4
You are unable to palpate distal pulses on the injured side
What would you do?
Compare circulation to opposite side
Contact Medical Control with the finding
Splint the injury as found
If pulses are found, mark the site with a pen
Makes it easier to find the pulse site on reassessment once found

73. Case Scenario #4 What do you do if loss of distal pulses?
Splint in position found
Notify receiving hospital of condition
Continue to monitor and assess the distal CMS/SMV/PMS status
Do not manipulate injuries without contacting Medical Control first
Document findings and interventions

74. Case Scenario #5
How do you care for an open wound?

75. Case Scenario #5 Can irrigate with normal saline for gross contaminant
Cover wound with moist sterile saline dressing
Cover with dry dressing
Immobilize extremity
Assume any open wound over a bony injury is an open fracture

76. Case Scenario #5 Goal: Reduce/eliminate further risk of contamination
Do not manipulate extremity
Do not want to inadvertently drag any contaminate into wound

77. Case Scenario #6 Sprain or fracture???
Do you handle a sprain different from a fracture?
Orthopedic/musculoskeletal injuries are handled the same
Will need further diagnostics for definitive diagnosis

78. Case Scenario #6 Wounds change appearance after hours to days
Usually develop more swelling and discoloration
Bruising from bleeding into surrounding tissue
Blood will get reabsorb over time
Color of bruise indicates general age of injury
Document color of bruise noted versus using words “new” or “old”

79. Age of Bruise/Injury 0 - 2 days – red 2 – 5 days – blue and purple
5 - 7 days – green
7 – 10 days – yellow
10 – 14 days – brown
2 -4 weeks – no further evidence

80. Case Scenario #7
Your patient was casted 2 days ago for a fractured fibula/tibia
You can see a cast on the lower extremity
Patient complains of pain “off the chart”
They are agitated, miserable, and demanding fro you to do something for the pain
Toes are swollen and discolored
Capillary refill is present

81. Case Scenario #7 What is your impression?
Patient may no have kept leg elevated
Patient may not have filled prescription for pain medication
Patient has a low pain tolerance level
Worse case scenario: patient has a compartment syndrome
This is a true emergency
If not recognized and treated promptly, patient may need amputation
Outstanding feature: pain out of proportion; pain with passive stretching

82. Case Scenario #7
What can you do in the field for possible compartment syndrome???
Elevate extremity
To reduce swelling
Apply ice packs to site
Can be effective even through a cast
Evaluate distal CMS/PMS/SMV and document
At the hospital, after evaluation, patient may receive a fasciotomy to relieve intense elevated pressures within the muscle compartment

83. Case Scenario #7 Fasciotomy left open until pressures go down
Patient eventually returns to surgery to have wounds closed

84. Bibliography
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady
Region X SOP’s; IDPH Approved January 6, 2012.
Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady