3 The Skeleton Provides structure and protection Axial skeleton – skull, vertebrae, and thoracic cageTransfer weight from upper to lower bodyResponsible for upright positionAppendicular skeleton – shoulder, arm, pelvis, legsResponsible for movementcontinued
4 The Skeleton continued (a) The appendicular skeleton. (b) The axial skeleton.continued
5 The Skeleton Types of Bones Long: Humerus, radius, ulna, femur, tibia, fibulaBreaks at epiphyseal line (growth plate) can be serious for growing childrenFlat: Skull, scapula, ribs, sternum, pelvisIrregular: Vertebrae, wrist, hands, ankle, feet, patella
6 JointsJoint: Two bones and the connective tissues that surround, support, and stabilize it called the joint capsule. Synovial fluid in the joint capsule lubricates joints.
7 Joints Range/type of motion depends on type of joint: Ball and socket: shoulder, hip.Hinge: knee, finger.Gliding: wrist, ankle.Pivot: base of thumb.Suture: pelvis, skull.
8 Ligaments and TendonsLigaments connect bone to bone, form part of joint capsuleRestrict the motion of the jointTightness/laxity help determine extent of movementTendons connect muscle to boneBoth can be stretched or tornStability and function suffer
9 Muscles Tissue contracts and relaxes – often work in pairs Controlled by nervous system – spinal and peripheralThree types:Skeletal (voluntary)SmoothCardiac
10 Physiology of Movement Skeletal muscle message is “contract”Signal provided by nervesMay be voluntary or involuntaryPairs work in coordination to flex and extend joints
11 The Healing ProcessFactors are extent of damage, age, nutrition, overall healthBone healing requires nutrients, oxygen, and immobilizationMuscles and ligaments heal slowlyTendons need protection during healingCartilage does not heal, it is often removed
12 Common Musculoskeletal Injuries SprainStretching or tearing of a ligamentTears may need surgeryJoint is displaced beyond its normal alignmentcontinued
13 Common Musculoskeletal Injuries StrainStretched or torn muscleOverexertion or poor body mechanicsMay range from minor to severeStrain versus SprainYou strain a muscle or tendon and sprain a ligament.continued
14 Common Musculoskeletal Injuries Tendon ruptureActive motion of joint may be lostAchilles heal and bicep are commonFractureBreak in a boneMay be open or closedMay be displaced or non-displacedMay be associated with internal or external bleedingcontinued
15 Common Musculoskeletal Injuries DislocationSeparation or displacement of bones at a jointUsually the result of forceful traumaMultiple structures and surrounding tissues may be injured in a single eventSoft tissues, nerves, and blood vessels may be involved
16 Common Musculoskeletal Injuries Two zones of injury. One is at femur fracture site, and the other is at the tibial fracture site.continued
19 Possible Blood Loss from Fractures Pelvis ( ml)Femur ( ml)Humerus ( ml)Tibia/Fibula ( ml)
20 Jams and Pretzels Six basic anatomical positions Position 1 – supine, neutral, straightPosition 1a – supine with variationsPosition 2 – on one side, neutral, straightPosition 2a – on one side with variationsPosition 3 – prone, neutral, head turnedPosition 3a – prone with variationsDiscussion Points: This complex set of skills will require much practice before students become comfortable with all of its methods and steps. This slide will allow discussion of the concept, but it is the demonstration and practice that will bring understanding and expertise.continued
21 Jams and PretzelsThree posterior reference points – head, shoulders, hipsThe goal is to keep them aligned and in the same plane during movesThey are secured in all moves (legs too if 4th rescuer is on scene)
22 Jams and Pretzels All moves are axial or vertical – never sideways Movements are made in short incrementsIf straightening of head, neck, or limbs is needed, do only one at a timeBegin with head/neck (for airway)Stop for major pain or resistanceEnd in Position 1 on a spine board
24 Management Deal with life threats General care has common steps Use BSIPlan of action to include help, equipment, and transport neededExpose injury to observe for bleeding, deformity, discoloration, swellingControl bleeding, bandage woundsDiscussion Points:Note that these are general principles. Most have been covered in previous chapters or courses.continued
25 Management General care has common steps Immobilize as needed – check CMSIce for swellingTransport to aid room, monitor patient comfortReassess for CMS and bleeding, adjust treatment as neededO2 as neededTransfer to higher level of careDiscussion Point:Emphasize reassessment, since a situation can change as the patient is brought in, or as they warm up in the first aid area.
26 Assessment Standard assessment procedures – ABCDs, SAMPLE, and vitals Determine number of patientsUse MOI to point to possible injuriesLook for guardingDiscussion Points:If students are not thoroughly familiar with general assessment procedures at this time such as scene size-up, marking the scene, etc. (Chapter 7) review here.ABCD, life threat treatments, and determination of responsiveness (primary assessment) are emphasized beforelooking for extremity injuries.Although head/neck/spine injuries are not covered in detail until the next chapter, stabilization is mentioned here.MOI, injury type, severity, and extent are detailed in the chapter. The text notes that head/neck/spine, and body core areas should be assessed before the extremities (severe extremity bleeding is the exception). Review the mnemonic as it relates to the secondary exam.The three most common signs and symptoms are mentioned here, others will be added in a later slide. Guarding behavior may be noted in the primary or secondary exam.continued
27 Assessment Thorough physical exam – DCAP-BTLS Pain/point tenderness, deformity, swelling are common signs and symptomsEvaluate each side separatelyAn important aspect of a secondary assessment is locating the point of tenderness.Copyright E. M. Singletary, MDcontinued
28 Assessment Note CMS distal to injury Palpate injured area last Expose injury siteOn scene to control bleedingIn aid room to shield from weather, for modestyFormulate management planReassess vitals/CMSDiscussion Points:Review CMS as needed. Although the chapter notes palpating the injured area last, it is important that OEC techs know the specific location of the chief complaint/injury before performing the full secondary exam.Note that some patients may not want any part of the extremity touched, or will scream in pain at any touch. The injury should be exposed as soon as possible, but use your judgment and, except for obvious bleeding, may be left until the patient reaches the aid room.See chapter for further details in the text regarding formulating the management plan that include personnel, equipment, and transport considerations.
29 Signs and Symptoms of Common MS Injuries Sprain, strain, ruptured tendonFractureClosed? Open?DislocationSigns and symptomsPain – worsens when movedBruising, wounds, skin “gaps” or “tents”Decreased motionCrepitusDiscussion Points:Each injury is covered in more detail in the chapter, including specific signs and symptoms.The purpose of this slide to provide a generalized list for discussion.The most common signs and symptoms of these injuries are listed on this slide; crepitus is the exception.
30 Upper Extremity Injuries Falling onto outstretched hand, elbow, shoulder may cause theseAssess from scapula to fingertipsScapula – SC jointClavicle - AC jointShoulderHumerus – elbow jointRadius/ulna – wrist jointHand, fingers, jointsDiscussion Points:Cover briefly pain, posture, and process in assessing the upper extremities. The next section covers the areas to be assessed from proximal to distal, with both bones and joints included.Students should be able to locate both bones and joints on themselves or a partner and note important surface anatomy points, as the next session covered assessment from proximal to distal.Depending on time, review major muscle groups and/or blood vessels found in association with the bones/joints.continued
31 Upper Extremity Injuries Clavicle is frequently fracturedSternoclavicular (SC) joint dislocation (posterior) may be life threateningShoulder (AC) separation / dislocation differ in character and severityAnterior dislocations more commonScapula fractures require severe MOIHumerus fractures may result in nerve damageDiscussion Points:Discuss the injuries to each bone or joint thoroughly.Focus on the SC joint dislocation due to its severity.Encourage students to share their experiences with any of these injuries.Share your experiences treating patients with these injuries; i.e. first time shoulder dislocations being extremely painful.The chapter includes details on the bones which may be involved in joint injuries, and also ligaments and tendons.continued
32 Upper Extremity Injuries Detecting Injury TypePatients with A/C injuries, clavicle fractures, scapular fractures, and humeral head and neck fractures generally hold their arm against their abdomen; patients with posterior shoulder dislocations hold their arm against their abdomen and will not let you bring the arm away from the abdomen (external rotation). By contrast, patients with anterior dislocated shoulders hold their arm out and up. Thus the position in which a patient holds the injured arm can help you identify the possible injury.Discussion Points:Discuss the injuries to each bone or joint thoroughly.Focus on the SC joint dislocation due to its severity.Encourage students to share their experiences with any of these injuries.Share your experiences treating patients with these injuries; i.e. first time shoulder dislocations being extremely painful.The chapter includes details on the bones which may be involved in joint injuries, and also ligaments and tendons.continued
33 Upper Extremity Injuries Elbow fractures involve bones – dislocations lock joints, CMS issuesRadius and/or ulna may fractureWrist fracture may involve distal radius/ulna (Colles) or carpal bonesSkier’s thumb common ligament injuryDiscussion Point:The chapter contains more details on these injuries, and should be covered in discussion.continued
34 Upper Extremity Injuries Copyright E. M. Singletary, MDCopyright E. M. Singletary, MD• A dislocation of the elbow.• A forearm injury.• An X-ray showing a fractured radius and ulna.• Skier's thumb.continuedCopyright E. M. Singletary, MDCopyright Edward McNamara
35 Lower Extremity Injuries Assess from pelvis to toesHip joint – femurKnee jointTibia/fibula – ankle jointFoot , toes, jointsFemur connects to pelvis at hip joint – may dislocate and/or fractureFemur fractures involve high energy traumaDiscussion Points:Additional details are included in the chapter on the various injuries that may occur at the hip.Emphasize the severity of femur injuries, regardless of which part. Each of the three “parts” of the femur are treated differently; review how to narrow down the injury site so that the correct treatment is applied.See chapter for details regarding fracture of the distal condyles and the severity of this injury.continued
36 Lower Extremity Injuries Knee ligament/cartilage injuries are commonTrue dislocation is an emergencyPatellas may fracture or dislocateTib and/or fib may fractureAnkle may sprain, fracture, dislocateLocation gives clue to injury typeFoot injury takes many formsDiscussion Points:The non-bone “parts” of the knee are commonly injured. Someone in the class my be willing to share an experience with a knee injury.Discuss injury to the proximal end of the tibula or fibula, and patella as it has both ligament and bone “parts”; also discuss other injuries as indicated in the chapter.Encourage students to share any tib/fib injuries. Typical injuries are boot top, so remind students that the “ankle” bones are, in fact part of the tib (medial) and fib (lateral).Discuss ankle injuries as they are also susceptible to injury. Use details from the chapter.
37 Lower Extremity Injuries A boot top fracture can involve the tibia, the fibula, or both bones.
38 Splinting Splint to: Prevent further tissue damage Allow easier transportPrevent paralysis in spinal injuriesDiscussion Point:Mention each as this is mostly straightforward material.
39 Principles of Splinting Splint before moving patientCheck CMS before and afterManually stabilize injured areaUse correct type/size, pad as neededPosition, move limb carefully, and secureIf shock is significant, work quickly and transportDiscussion Points:The information on the next three slides will become much of the mantra of your practice sessions, as well as the backbone of the treatment of many of your patients:Checking CMSManual stabilizationCorrect size and type of splintCare in moving injured limbsAll of the above are second nature to OEC techs, and applies to your students as well.Note the last bullet: When a patient’s general condition is deteriorating, it may be more important to transport than to spend time splinting MS injuries.continued
40 Principles of Splinting If deformity is present with fracture, align if possibleIf alignment is not possible, secure in best position for stability/comfortOpen fractureSeverely angulated or “locked”Dislocations and/or fracture at jointPatient who will not allow movementInjury with impaled objectDiscussion Points:Alignment is mentioned several times in the chapter:In relation to straightening a long bone fracture before splinting (efficiency and improving patient comfort)To re-establish distal CMSJoint splinting in position found (if CMS is compromised AND a 2+ hour wait for hospital care)Increased pain and resistance may be cause to abandon alignment of a long bone and splint in position found (improvised splinting)continued
41 Principles of Splinting Do not attempt to reduce fractures or force bone ends back into skinRemove jewelry before swelling occurs – account for itImmobilize above and below injury site (bones for joint injury, joints for bone injury)Advise patient to seek follow-up careDiscussion Points:Ensure students understand the difference between aligning and reducing a fracture.The chapter mentions that bones may pull back into the skin with alignment, especially in relation to traction splinting. This is different from forcing the bone ends back in.If jewelry is removed, ensure that the patient has it with them when they leave to avoid accusations of theft related to our care.The last two bullets on the slide are not mentioned specifically in the principles of splinting section of the chapter, but appear in the various descriptions of splinting specific injuries.
42 Quick Splint Replacement Many quick splinted injuries are repackaged in the first aid areaConsider not replacing a quick splint if there are:Serious multiple injuriesVery unstable fracturesBandaged open fracturesFractures accompanied by advancing shock
43 Chapter Summary The most frequent injury in skiing is a knee sprain. The most frequent injury while snowboarding is a distal radius fracture.A common upper extremity injury among skiers is skier’s thumb.Discussion Points:This chapter represents the information and skills that OEC techs use the most often.If you have summarized each section as you have gone through the chapter you may want to limit this summary to the management section.continued
44 Chapter SummaryThe clavicle is the most commonly broken bone in the body.For extremity injuries, remove all rings, bracelets, or other jewelry from the hand or foot immediately, before swelling occurs.Treat all threats to life first, and then manage musculoskeletal injuries.