1. LESSON 18
INJURIES TO
MUSCLES AND BONES

2. Introduction
Trauma patients often have considerable musculoskeletal injuries
With significant mechanisms of injury, bones may fracture and joints may be injured
Injuries may result in pain, disability and life-threatening bleeding

3. Musculoskeletal System Review
Bones
Muscles
Tendons
Ligaments

4. Primary Functions of Musculoskeletal System
Provide shape and support for body
Muscles acting on bones allow movement
Bones protect vital internal organs

5. Types of Muscles Skeletal muscles  voluntary
Smooth muscles  involuntary
Cardiac muscle  involuntary
All muscle activity controlled by nervous system

6. Mechanisms of Injury to Musculoskeletal System
Direct force: force applied directly to body
Indirect force: force transferred from original body site along an extremity to another point
Twisting forces: part of body forced to move in unnatural direction

7. Factors Involved in Injuries
The greater the force:
The more likely the injury
Fracture/Joint dislocation severity more likely
Patient’s age and health status

8. Types of Musculoskeletal Injuries
EMRs need not determine type of musculoskeletal injury:
Fractures
Dislocations
Sprains
Muscle injuries

9. Fractures Bone may be completely broken or only cracked
Closed fracture  skin not broken
Open fracture  open wound at site

10. Dislocations

11. Dislocations (continued)
One or more bones at joint displaced from normal position
Ligaments holding bone are torn
Result from strong forces
Sometimes accompanied by bone fractures or other injuries
Can be very painful

12. Dislocations (continued)
Patient cannot use joint due to pain or structural damage
Serious bleeding may result
Nearby nerves may be injured
With severe dislocation, joint or limb will look deformed

13. Sprains Joint injury involving ligament stretching and tearing
Typically occur when joint is overextended
Can be mild or severe
Ankles, knees, wrists, fingers most common
Considerable swelling often occurs rapidly

14. Muscle Injuries Strains, contusions, cramps
Usually less serious than fractures and joint injuries
Many causes

15. Recognizing Musculoskeletal Injury
Sometimes injury type is obvious
Often you will recognize musculoskeletal injury if present
Emergency care is same regardless of injury type
Usually not life-threatening
May be serious and result in pain and disability

16. Assessment of Musculoskeletal Injuries
Perform standard assessment
Ask patient what happened and what was felt
If large forces involved, consider potential for spinal injury
Expose injury site carefully
Amount of pain and swelling not indicator of injury severity
Immediate medical treatment if no circulation or possible nerve damage

17. Assess for Circulation, Sensation and Movement (CSM) Below the Injury Site
Check pulse below injury
Check skin color and temperature
Touch fingers or toes
Does patient feel touch, tingling sensation, numbness?
Have patient wiggle fingers or toes

18. Signs and Symptoms of Musculoskeletal Injury

19. Signs and Symptoms of Musculoskeletal Injury (continued)
Pain and tenderness
Abnormal sensation (numbness, tingling)
Inability to move area
Joint locked into position
Impaired function or circulation
Difference in temperature from opposite extremity

20. Preventing Movement Movement causes injury, pain, swelling
Bone movement further injures soft tissues
Movement generally increases blood flow - may increase internal bleeding and swelling
Manually stabilize or splint injured area

21. Emergency Care of Musculoskeletal Injuries
Perform standard patient care
Control any life threats
Allow patient to be in position of comfort
Cover open wounds with sterile dressing
Apply cold pack with skin barrier
Don’t replace protruding bones

22. Emergency Care of Musculoskeletal Injuries (continued)
Stabilize injured extremity manually
Support above and below injury
If appropriate, splint extremity
Follow local protocol for oxygen
With traumatic amputation of a body part, care for amputated part after stabilizing patient

23. Splinting

24. Splinting
Movement may worsen musculoskeletal injury and cause more pain
Splint injured arm or leg if risk of area being moved (unless help expected quickly)
Always splint an extremity before patient is transported

25. Splinting (continued)
Helps prevent further injury
Reduces pain
Minimizes bleeding and swelling

26. Types of Splints Rigid splints Soft splints
Air splints (inflatable splints)
Pneumatic splints
Anatomic splints
Improvised splints

27. Rigid Splint Board Plastic or metal Rolled newspaper or magazine
Thick cardboard

28. Soft Splint Pillow Folded blanket or towel
Triangular bandage folded into sling

29. Anatomic Splint
Bandage injured leg or finger to uninjured one

30. Commercial Splints

31. Securing Splints Use bandages, strips of cloth, Velcro
Use knots that can be untied
Don’t secure with tape to skin

32. Guidelines for All Splints
Dress open wounds
Splint only if it doesn’t cause more pain
Splint in position found
Immobilize entire area (joints above and below injury)
Pad between splint and skin
Assess CSM before and after splinting
Put splints on both sides of fracture if possible
Apply cold pack to injury around splint

33. Guidelines for Slings
Use sling to prevent movement and to elevate extremity
Splint injury first
If you splint injury in position found and this position makes use of sling difficult  do not use sling

34. Guidelines for Slings (continued)
Do not move arm into position for sling if it causes pain
A cold pack can be used inside sling
Do not cover fingers inside sling

35. Skill: Applying Arm Sling and Swathe

36. Secure point of bandage at elbow

37. Position triangular bandage

38. Bring lower end of bandage to opposite side of neck

39. Tie the ends

40. Tie swathe bandage over sling and around chest

41. Shoulder Injuries Involve clavicle, scapula or joint structures
Clavicle is most frequently fractured bone
Scapula fractures are rare
Shoulder dislocations are common

42. Splinting Shoulder Injuries
Goal is to stabilize area from trunk to upper arm
Use soft splint; do not move extremity
Assess for circulation, sensation and movement

43. Splinting Shoulder Injuries (continued)
Pad hollow between body and arm
Apply sling and swathe to support and immobilize arm – if this causes pain use larger pillow

44. Upper Arm Injuries Immobilize humerus fractures with rigid splint
Treat fractures near shoulder with soft splint

45. Splinting Upper Arm Injuries
Stabilize bone between shoulder and elbow
Assess circulation, sensation, movement in hand and fingers
Apply rigid splint along outside of arm

46. Splinting Upper Arm Injuries (continued)
Tie splint above injury and at elbow
Support wrist with sling and wide swathe
If it causes pain to raise wrist for a sling, use long rigid splint

47. Elbow Injuries Sprains and dislocations are common
Fractures occur above or below elbow
Patient unable to move joint

48. Splinting Elbow Injuries
If elbow bent, apply rigid splint from upper arm to wrist
If more support needed, use sling at wrist and swathe around chest

49. Splinting Elbow Injuries (continued)
If elbow straight, apply rigid splint from upper arm to hand
If more support needed, use swathes around chest and upper arm and lower arm and waist

50. Skill: Splinting a Forearm

51. Support arm and check circulation

52. Position arm on rigid splint

53. Secure splint
Put splinted arm in sling and swathe

54. Check circulation

55. Wrist Injuries
Sprains
Fractures

56. Splinting Wrist Injuries
Goal is to stabilize from forearm to hand
Soft splint and sling often sufficient
Rigid splint provides more support
Assess circulation, sensation, movement in hand and fingers

57. Splinting Wrist Injuries (continued)
Apply rigid splint on palm side of arm from forearm past fingertips
Tie above and below wrist
Leave fingers uncovered
Support forearm and wrist with sling and apply binder around upper arm and chest

58. Hand Injuries May be injured by direct blow
Fractures occur when patient punches something with closed fist

59. Splinting Hand Injuries
Goal is immobilization of hand – use soft or rigid splint
Place roll of gauze in palm
Bandage entire hand  leave fingers exposed if possible to check CSM
Place rigid splint on palm side of hand; pad between hand and splint
Support further with sling and swathe

60. Finger Injuries Fractures and dislocations
Often a splint is not required
Use rigid splint or anatomic splint

61. Splinting Finger Injuries
Use soft splint if finger cannot be straightened without pain
Don’t manipulate finger into normal position
Use rigid splint, secured with tape  or anatomic splint by taping finger to adjoining finger with gauze in between

62. Lower Extremity Injuries
Larger forces are typically involved – forces may also cause spinal injury
Assess patient without moving extremity
Femur fracture can damage femoral artery and cause life-threatening bleeding

63. Hip and Pelvis Injuries
Fractures and dislocations
Hip fracture: fracture of top part of femur
Fractures more common in elderly due to osteoporosis
Bleeding and pain may be severe
Dislocations can occur at any age:
Falls
Vehicular crashes
Blows to body

64. Splinting Hip and Pelvis Injuries
Do not move patient
Immobilize leg and hip in position found
Pad between legs and bandage together (unless this causes more pain)
Treat for shock but do not elevate legs

65. Upper Leg Injuries Femur fractures are serious
Severe pain and shock may occur
Keep patient from moving
Rigid splint unnecessary if patient is lying down with leg supported by ground
Use folded blankets or coats to immobilize leg in position found

66. Splinting Upper Leg Injuries
Anatomic splint
Rigid splints

67. Splinting Upper Leg Injuries (continued)
Check circulation and sensation in foot and toes
Put rigid splint on each side of leg
Pad body areas and voids
Inside splint should extend from groin past foot
Outside splint should extend from armpit past foot

68. Anatomic Splinting of Leg Injuries
Gently slide 4 or 5 bandages under both legs  but not over injury
Put padding between legs
Do not move injured leg
Gently slide uninjured leg next to injured leg
Tie bandages
Check circulation again

69. Traction Splint for Femur Fractures
Traction splint maintains continual pull on femur to keep bone ends in normal position
EMRs may assist other EMS personnel

70. Knee Injuries Sprains Dislocations Caused by:
Sports injuries
Motor vehicle crashes
Falls
Femur, tibia or fibula fractures are indistinguishable from knee injuries

71. Splinting Knee Injuries
Splint in position found
Apply soft splint by rolling blanket or placing pillow around knee
If knee straight, make anatomical splint

72. Splinting Knee Injuries (continued)
If possible, put rigid splint on both sides of leg
Pad body areas and voids
Check circulation and sensation in foot and toes first and periodically after splinting

73. Splinting Knee Injuries (continued)
If knee is straight, apply 2 splints along both sides of knee
If knee is bent, splint in position found
Tie splints with cravats or bandages

74. Lower Leg Injuries Commonly caused by:
Sports
Motor vehicle crashes
Falls
Either or both bones of lower leg can be fractured

75. Lower Leg Injuries (continued)
Rigid splint applied the same as for knee injury
3-sided cardboard splint can be used

76. Skill: Splinting the Leg (Anatomic)

77. Check circulation
Gently slide 4 to 5 strips of bandages under both legs

78. Pad between legs

79. Gently slide uninjured leg next to injured leg

80. Tie bandages and check circulation

81. Ankle Injuries
Sprain may occur when foot is forcefully twisted to one side
Fractures or dislocations
Often involve torn ligaments and nerve or blood vessel damage

82. Splinting Ankle Injuries
Soft splint usually best
Gently remove the shoe to assess circulation, sensation, movement in toes
Tie pillow around foot and lower leg
For minor ankle injury not requiring splinting, elastic roller bandage may be used for compression

83. Applying a Figure-8 Bandage to the Ankle
Anchor starting end of bandage
Turn bandage diagonally across top of foot and around ankle, and bring bandage around in a figure-8
Continue with overlapping figure-8 turns
Fasten end of bandage with clips, tape or safety pins

84. Foot Injuries Commonly caused by:
Direct blows
Falls
Involve almost any bone or ligament of foot
Treat same as ankle injuries
Toe fractures can be very painful

85. Splinting Foot Injuries
Usually no splinting required
Use pillow splint as for ankle injury if:
Toe is significantly bent
More than 1 toe involved
Foot is very painful

86. Rib Fractures Typically caused by blunt trauma to chest
More common in lower ribs and along side
Cause severe pain, discoloration, swelling
Pain often sharper upon breathing in
Patient may breathe shallowly and hold or support area

87. Splinting Rib Injuries
Goal is primarily supportive
Have patient sit or stand in position for easy breathing
Support ribs with pillow or soft padding loosely bandaged over area and under arm
Immobilize arm with sling and swathe
Monitor breathing