Musculoskeletal Injuries June/July 2013 CE Condell Medical Center EMS System Site Code: 107200E-1213 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

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.

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.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

Fentanyl cont’d Onset - immediate Peak effect – 3 – 5 minutes Duration 30 - 60 minutes IN route used in absence of IV access Administer in divided doses IN route onset 2 minutes

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

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

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

Compartments of the Leg

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

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

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

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

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

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

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

HARE Traction For suspected mid-shaft femur fractures

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

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

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

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

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

Sager Splint Alternative device for suspected femur fractures

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

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

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

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

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

KED Device

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

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

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

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

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

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

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

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

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

Case Scenario #2 - MOI

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

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

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

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

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

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

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 50-60-60 Lidocaine 50 mg over 1 minute and wait 1 minute to resume infusion

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

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

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

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

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

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

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

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”

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

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

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

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

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

Bibliography Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013. Region X SOP’s; IDPH Approved January 6, 2012. Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010.