1. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Division 3 Trauma Emergencies

2. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 22 Musculoskeletal Trauma

3. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Topics Introduction to Musculoskeletal Trauma Anatomy and Physiology of the Musculoskeletal System Pathophysiology of the Musculoskeletal System Musculoskeletal Injury Assessment Musculoskeletal Injury Management

4. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Introduction to Musculoskeletal Injuries Millions of Americans experience annually Multiple MOI –Falls, crashes, violence, etc. –Multi-system trauma

5. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Musculoskeletal System Skeletal Tissue and Structure –Give the body its structural form –Protect vital organs –Promote efficient movement despite the forces of gravity –Store salts and other materials needed for metabolism –Produce red blood cells

6. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal System Bone Structure –Diaphysis –Epiphysis End of a long bone –Metaphysis Between epiphysis and diaphysis Growth plate –Medullary canal Contains bone marrow –Periosteum Fibrous covering of diaphysis –Cartilage Connective tissue that provides a smooth articulation surface for other bones

7. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Musculoskeletal System Joint Structure –Joint Where bones interact –Synarthrosis A joint that does not permit movement –Diarthroses (synovial joints) Monaxial: hinge or pivot joints Biaxial: gliding, sliding, or saddle joints Triaxial: ball and socket joints –Ligaments –Joint capsule Synovial fluid

8. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Joint Structure (1 of 2)

9. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Joint Structure (2 of 2)

10. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Musculoskeletal System (1 of 3) Skeletal Organization –206 bones –Axial skeleton Head, thorax, and spine –Appendicular skeleton Upper extremities Lower extremities

11. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Bone Aging –Birth to adult (18–20) Transition from flexible to firm bone –Adult to elderly (40+) Reduction in collagen matrix and calcium salts Diminution of bone strength Spinal curvature Anatomy and Physiology of the Musculoskeletal System (2 of 3)

12. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology of the Musculoskeletal System (3 of 3) Types of Muscles –Smooth –Striated –Cardiac Muscular Tissue and Structure –600 muscle groups

13. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Muscles

14. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal System

15. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Muscular Injury Contusion Compartment Syndrome Penetrating Injury Fatigue Muscle Cramp Muscle Spasm Strain Pathophysiology of the Musculoskeletal System (1 of 5)

16. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology of the Musculoskeletal System (2 of 5) Joint Injury –Sprain –Subluxation –Dislocation Bone Injury –Open fracture –Closed fracture –Hairline fracture –Impacted fracture –Transverse

17. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology of the Musculoskeletal System (3 of 5) Pediatric Considerations –Flexible nature Geriatric Considerations –Osteoporosis Pathological Fractures –Pathological diseases

18. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology of the Musculoskeletal System (4 of 5) General Considerations with Musculoskeletal Injuries –Neurological compromise –Decreased stability –Muscle spasm Bone Repair Cycle –Osteocytes produce osteoblasts –Deposition of salts –Increasing strength of matrix

19. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology of the Musculoskeletal System (5 of 5) Inflammatory and Degenerative Conditions –Bursitis –Tendonitis –Arthritis Osteoarthritis Degenerative Rheumatoid arthritis Chronic, systemic, progressive, debilitating Gout Inflammation of joints produced by accumulation of uric acid crystals

20. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Assessment (1 of 2) Scene Size-up –Clues to specific injuries. –Pelvic fractures or bilateral femur fractures are “Load and Go.” –Control major bleeding. –History may suggest other injuries. Initial Assessment –Categories of urgency Life- and limb-threatening injury Life-threatening injury and minor musculoskeletal injury Non-life-threatening injuries but serious musculoskeletal injuries Non-life-threatening injuries and only isolated minor musculoskeletal injuries

21. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Assessment (2 of 2) Rapid Trauma Assessment –Only press on pelvis if no clinical signs of injury are present such as pain. Focused H&P –6 Ps: Pain, Pallor, Paralysis, Paresthesia, Pressure, Pulses Detailed Physical Exam Ongoing Assessment Sports Injury Considerations

22. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Detailed Exam of Extremities Deformity Contusions Abrasions Penetrations Burns Tenderness Lacerations Swelling Also check PMS.

23. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management (1 of 2) General Principles –Protecting open wounds –Positioning the limb –Immobilizing the injury –Checking neurovascular function Pulse Palpate Utilize pulse oximetry Motor Sensation

24. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management (2 of 2) Splinting Devices –Rigid splints –Formable splints Vacuum splints Air splints –Soft splints –Traction splints –Other splinting aids Cravats or Velcro splints Fracture Care Joint Care Muscular and Connective Tissue Care

25. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Care for Specific Fractures (1 of 4) Pelvis –Scoop stretcher –Pelvic sling device PASG as a reserve device only –Fluid resuscitation

26. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Care for Specific Fractures (2 of 4) Femur Fractures –Traction splints Contraindicated in hip/knee injuries –PASG –High-force injury –High potential for shock

27. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Care for Specific Fractures (3 of 4) Tibia-Fibula Fractures –Frequently open fractures. –Cover bone ends with moist dressing. –Depending on level of fracture, use: Rigid splint Air splint Pillow

28. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Care for Specific Fractures (4 of 4) Clavicle –Most frequently fractured bone in the body –Transmitted to 1st and 2nd rib –Alert for lung injury

29. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Care for Specific Joint Injuries –Hip –Knee –Ankle –Foot –Shoulder –Elbow –Wrist/Hand –Finger Be alert for neurological compromise.

30. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hip Fractures Common in the elderly. May be able to support weight. –Ability to walk does not rule out fracture. Leg often externally rotated. May refer pain to the knee. Use other leg for splint. Use vacuum mattress if available.

31. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hip Dislocation Orthopedic emergency Posterior dislocation most common Hip flexed and leg rotated internally Severe pain on attempts to straighten

32. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Hip Dislocation Management Splint in most comfortable position. Document sensation and pulse. Prompt transport. Be alert for associated knee injuries or fractures.

33. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Knee Fracture or Dislocation Orthopedic emergency Frequently causes vascular injury Dislocation associated with 50% rate of amputation of leg

34. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Knee Fracture or Dislocation Management Obvious dislocation without distal pulse: –Apply gentle traction along the long axis of the joint. If gentle traction does not restore the pulse: –Splint in place. Prompt transport.

35. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Foot or Hand Injury Common industrial injury. Often disabling. Rarely life threatening. Splint foot with pillow. Splint hand in position of function.

36. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Shoulder Injury AC Separation –Sling and swathe. Shoulder Dislocation –Use pillow with sling and swathe. Fracture –Use sling and swathe.

37. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Elbow Injury Fracture or dislocation may cause neurovascular injury. Splint in position found. Transport promptly.

38. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Forearm/Wrist Injury Rigid Splint –Keep hand in “position of function.” Air Splint –May be hard to reassess circulation. Pillow

39. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Soft and Connective Tissue Injuries –Tendon –Ligament –Muscle

40. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Medications (1 of 4) Nitrous Oxide –50% O 2 :50% N 2 O –Non-explosive –Effects dissipate in 2–5 minutes –Easily diffused into air-filled spaces in body –Dose Inhaled and self administered –Onset 1–2 minutes Diazepam –Benzodiazepine –Antianxiety –Analgesic –Dose 5–15 mg titrated –Onset 10–15 minutes –Duration 15–60 minutes –Counter agent Flumazenil

41. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Medications (2 of 4) Morphine Sulfate –Opiate alkaloid. –Reduces vascular volume and cardiac preload. –Do not administer to hypovolemic patients. –Dose: 2 mg IVP slow –Counter agent: Narcan

42. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Medications (3 of 4) Meperidine –Demerol –Narcotic analgesic –Dose 50–100 mg –Counter agent Narcan

43. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Medications (4 of 4) Sublimaze –Fentanyl –Synthetic opioid –Equivalent to morphine –Dose 25–50 mg SIVP followed by an additional 25 mg as needed –Onset Less than a minute –Duration 3–6 hours –Considerations If given too rapidly, chest wall rigidity may ensue, leading to respiratory compromise.

44. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Musculoskeletal Injury Management Other Injury Considerations –Pediatric musculoskeletal injury –Athletic musculoskeletal injury –Patient refusals and referral –Psychological support

45. Bledsoe et al., Essentials of Paramedic Care: Division 1II © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Summary Introduction to Musculoskeletal Trauma Anatomy and Physiology of the Musculoskeletal System Pathophysiology of the Musculoskeletal System Musculoskeletal Injury Assessment Musculoskeletal Injury Management