Musculoskeletal Injuries Chapter 20, Section 1 Musculoskeletal Injuries

The Skeleton Provides structure and protection Axial skeleton – skull, vertebrae, and thoracic cage Transfer weight from upper to lower body Responsible for upright position Appendicular skeleton – shoulder, arm, pelvis, legs Responsible for movement continued

The Skeleton continued (a) The appendicular skeleton. (b) The axial skeleton. continued

The Skeleton Types of Bones Long: Humerus, radius, ulna, femur, tibia, fibula Breaks at epiphyseal line (growth plate) can be serious for growing children Flat: Skull, scapula, ribs, sternum, pelvis Irregular: Vertebrae, wrist, hands, ankle, feet, patella

Joints Joint: Two bones and the connective tissues that surround, support, and stabilize it called the joint capsule. Synovial fluid in the joint capsule lubricates joints.

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.

Ligaments and Tendons Ligaments connect bone to bone, form part of joint capsule Restrict the motion of the joint Tightness/laxity help determine extent of movement Tendons connect muscle to bone Both can be stretched or torn Stability and function suffer

Muscles Tissue contracts and relaxes – often work in pairs Controlled by nervous system – spinal and peripheral Three types: Skeletal (voluntary) Smooth Cardiac

Physiology of Movement Skeletal muscle message is “contract” Signal provided by nerves May be voluntary or involuntary Pairs work in coordination to flex and extend joints

The Healing Process Factors are extent of damage, age, nutrition, overall health Bone healing requires nutrients, oxygen, and immobilization Muscles and ligaments heal slowly Tendons need protection during healing Cartilage does not heal, it is often removed

Common Musculoskeletal Injuries Sprain Stretching or tearing of a ligament Tears may need surgery Joint is displaced beyond its normal alignment continued

Common Musculoskeletal Injuries Strain Stretched or torn muscle Overexertion or poor body mechanics May range from minor to severe Strain versus Sprain You strain a muscle or tendon and sprain a ligament. continued

Common Musculoskeletal Injuries Tendon rupture Active motion of joint may be lost Achilles heal and bicep are common Fracture Break in a bone May be open or closed May be displaced or non-displaced May be associated with internal or external bleeding continued

Common Musculoskeletal Injuries Dislocation Separation or displacement of bones at a joint Usually the result of forceful trauma Multiple structures and surrounding tissues may be injured in a single event Soft tissues, nerves, and blood vessels may be involved

Common Musculoskeletal Injuries Two zones of injury. One is at femur fracture site, and the other is at the tibial fracture site. continued

Types of Fractures Types of fractures.

Butterfly and Impacted

Possible Blood Loss from Fractures Pelvis (1300-1500 ml) Femur (500-1000ml) Humerus (300-500ml) Tibia/Fibula (150-250ml)

Jams and Pretzels Six basic anatomical positions Position 1 – supine, neutral, straight Position 1a – supine with variations Position 2 – on one side, neutral, straight Position 2a – on one side with variations Position 3 – prone, neutral, head turned Position 3a – prone with variations Discussion 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

Jams and Pretzels Three posterior reference points – head, shoulders, hips The goal is to keep them aligned and in the same plane during moves They are secured in all moves (legs too if 4th rescuer is on scene)

Jams and Pretzels All moves are axial or vertical – never sideways Movements are made in short increments If straightening of head, neck, or limbs is needed, do only one at a time Begin with head/neck (for airway) Stop for major pain or resistance End in Position 1 on a spine board

Management Deal with life threats General care has common steps Use BSI Plan of action to include help, equipment, and transport needed Expose injury to observe for bleeding, deformity, discoloration, swelling Control bleeding, bandage wounds Discussion Points: Note that these are general principles. Most have been covered in previous chapters or courses. continued

Management General care has common steps Immobilize as needed – check CMS Ice for swelling Transport to aid room, monitor patient comfort Reassess for CMS and bleeding, adjust treatment as needed O2 as needed Transfer to higher level of care Discussion Point: Emphasize reassessment, since a situation can change as the patient is brought in, or as they warm up in the first aid area.

Assessment Standard assessment procedures – ABCDs, SAMPLE, and vitals Determine number of patients Use MOI to point to possible injuries Look for guarding Discussion 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

Assessment Thorough physical exam – DCAP-BTLS Pain/point tenderness, deformity, swelling are common signs and symptoms Evaluate each side separately An important aspect of a secondary assessment is locating the point of tenderness. Copyright E. M. Singletary, MD continued

Assessment Note CMS distal to injury Palpate injured area last Expose injury site On scene to control bleeding In aid room to shield from weather, for modesty Formulate management plan Reassess vitals/CMS Discussion 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.

Signs and Symptoms of Common MS Injuries Sprain, strain, ruptured tendon Fracture Closed? Open? Dislocation Signs and symptoms Pain – worsens when moved Bruising, wounds, skin “gaps” or “tents” Decreased motion Crepitus Discussion 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.

Upper Extremity Injuries Falling onto outstretched hand, elbow, shoulder may cause these Assess from scapula to fingertips Scapula – SC joint Clavicle - AC joint Shoulder Humerus – elbow joint Radius/ulna – wrist joint Hand, fingers, joints Discussion 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

Upper Extremity Injuries Clavicle is frequently fractured Sternoclavicular (SC) joint dislocation (posterior) may be life threatening Shoulder (AC) separation / dislocation differ in character and severity Anterior dislocations more common Scapula fractures require severe MOI Humerus fractures may result in nerve damage 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

Upper Extremity Injuries Detecting Injury Type Patients 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

Upper Extremity Injuries Elbow fractures involve bones – dislocations lock joints, CMS issues Radius and/or ulna may fracture Wrist fracture may involve distal radius/ulna (Colles) or carpal bones Skier’s thumb common ligament injury Discussion Point: The chapter contains more details on these injuries, and should be covered in discussion. continued

Upper Extremity Injuries Copyright E. M. Singletary, MD Copyright E. M. Singletary, MD • A dislocation of the elbow. • A forearm injury. • An X-ray showing a fractured radius and ulna. • Skier's thumb. continued Copyright E. M. Singletary, MD Copyright Edward McNamara

Lower Extremity Injuries Assess from pelvis to toes Hip joint – femur Knee joint Tibia/fibula – ankle joint Foot , toes, joints Femur connects to pelvis at hip joint – may dislocate and/or fracture Femur fractures involve high energy trauma Discussion 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

Lower Extremity Injuries Knee ligament/cartilage injuries are common True dislocation is an emergency Patellas may fracture or dislocate Tib and/or fib may fracture Ankle may sprain, fracture, dislocate Location gives clue to injury type Foot injury takes many forms Discussion 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.

Lower Extremity Injuries A boot top fracture can involve the tibia, the fibula, or both bones.

Splinting Splint to: Prevent further tissue damage Allow easier transport Prevent paralysis in spinal injuries Discussion Point: Mention each as this is mostly straightforward material.

Principles of Splinting Splint before moving patient Check CMS before and after Manually stabilize injured area Use correct type/size, pad as needed Position, move limb carefully, and secure If shock is significant, work quickly and transport Discussion 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 CMS Manual stabilization Correct size and type of splint Care in moving injured limbs All 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

Principles of Splinting If deformity is present with fracture, align if possible If alignment is not possible, secure in best position for stability/comfort Open fracture Severely angulated or “locked” Dislocations and/or fracture at joint Patient who will not allow movement Injury with impaled object Discussion 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 CMS Joint 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

Principles of Splinting Do not attempt to reduce fractures or force bone ends back into skin Remove jewelry before swelling occurs – account for it Immobilize above and below injury site (bones for joint injury, joints for bone injury) Advise patient to seek follow-up care Discussion 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.

Quick Splint Replacement Many quick splinted injuries are repackaged in the first aid area Consider not replacing a quick splint if there are: Serious multiple injuries Very unstable fractures Bandaged open fractures Fractures accompanied by advancing shock

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

Chapter Summary The 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.