1. Musculoskeletal Emergencies
Emergency Nursing Core Curriculum
Acknowledgement is made to the following expert for the development of this module: Karen Belotti, RN, BSN
2007
Reviewed 2010

2. Musculoskeletal Emergencies Objectives
For selected musculoskeletal emergencies the participant will be able to:
Compare the etiology
Describe assessment findings
Identify the clinical management

3. Musculoskeletal Emergencies Always remember…..
First priority of care s

4. Musculoskeletal Emergencies The basics
Bleeding control
Immobilization
Neurovascular assessment
Orthopedic injuries can look really ugly – but most of the time the patient will NOT die as a result of an extremity fracture.
Neurovascular assessments (more than one) imperative to the preservation of limbs

5. Musculoskeletal Emergencies
Strains
and
Sprains

6. Musculoskeletal Emergencies Strains - definition
The result of over stretching a muscle at the point of attachment to the tendon
Is often caused by overuse, force, or stretching.

7. Musculoskeletal Emergencies Sprains - definition
A wrenching or twisting injury to a ligament with hyperextension, hyperflexion or torsion of a joint
Most common sites are ankles, knees and shoulders.
Generally more traumatic in nature than a strain.

8. Musculoskeletal Emergencies Sprains
The most commonly sprained or strained joint is the ankle
Ankle Sprains
Approximately 1 million ankle injuries occur each year, and 85 percent of them are sprains.
Ankle sprains can occur during competitive sports or during routine daily activities (walking).
The length of recovery can be as long as a fracture (6-10 weeks), and it is important to wait for healing and rehabilitation to be complete prior to returning to his/her sport.

9. Musculoskeletal Emergencies Strains & Sprains – signs & symptoms
Mild to severe pain with disability and loss of function.
May describe a snapping or popping sound
Point tenderness

10. Musculoskeletal Emergencies Strains & Sprains – signs & symptoms
Mild to severe edema
Ecchymosis
Mild to marked deformity

11. Need to know pregnancy status of women before radiological studies

12. Musculoskeletal Emergencies Strains & Sprains - treatment
Immobilization
Elevation
Ice
Rest
Analgesia
elevation (above level of heart) for 24 to 72 hours
ice pack for 24 to 48 hours (protect the skin! Never apply ice packs directly to skin. Tissue damage may result.)
rest - light to no weight-bearing with crutches
Degree of immobilization dependent on severity of injury:
compression bandage (ace wrap)
splint
stirrup ankle brace
cast

13. Musculoskeletal Emergencies Strains & Sprains - Pneumonic:
PRICE
Protect
Rest
Ice
Compression
Elevation

14. Musculoskeletal Emergencies Fractures
Disruption in the normal continuity of the bone, cartilage or both

15. Musculoskeletal Emergencies Fractures - types
Oblique
Spiral
Comminuted
Impacted
Compression
Greenstick
Avulsion
Depressed
Open vs. Closed

16. Musculoskeletal Emergencies Fractures - Oblique
Oblique: Fracture resulting from a twisting force
these types of fractures are one of rarest forms.
an oblique break in the bone is very unstable
break at an angle
they can easily be misdiagnosed as spiral fractures

17. Musculoskeletal Emergencies Fractures - Spiral
Twisting force while foot firmly planted
bone broken due to a twisting type motion.
highly unstable
may be diagnosed as a oblique fracture unless the correct x-ray has been ordered.
will appear like a corkscrew which runs parallel with the axis of the broken bone

18. Musculoskeletal Emergencies Fractures - Comminuted
Severe direct force causes more than two bone fragments
fracture in which bone is broken, splintered or crushed into a number of pieces.
considered comminuted when at least 3 bone fragments.
highly unstable

19. Comminuted

20. Musculoskeletal Emergencies Fractures - Impacted
Fractured bone ends jam together
ends are driven into each other
commonly seen in pediatric arm fractures
also known as a ‘buckle’ fracture.
generally occurs after a fall in which the vertebral column is compressed:
extreme pressure causes cracks or breaks.
may also be referred to as a compression fracture.

21. Musculoskeletal Emergencies Fractures - Compression
Severe force jams vertebrae together
caused by Injuries that forces the vertebrae together ( fall landing on head or sacrum)
may also be referred to as a impact fracture.

22. Musculoskeletal Emergencies Fractures - Greenstick
Compression force, most commonly seen in children
an incomplete fracture in which only one side of the bone has been broken.
bone usually is "bent" and only broken on the outside of the bend.
mostly seen in children
considered a stable fracture due to the fact that the whole bone has not been broken.
if bone kept rigid healing is usually rapid.

23. Musculoskeletal Emergencies Fractures - Avulsion
Forceful contraction of muscle mass causes bone to break away from insertion point
injury to the bone in a place where a tendon or ligament attaches
avulsion fracture pulls a piece of tendon or ligament off the bone.
more common in children than adults:
weak point called the growth plate
area of bone that is actively growing.
tendons or ligaments near growth plate can pull hard enough to cause the growth plate to fracture.
can also occur when a muscle-tendon unit exerts such traction force on the bone it is attached to, it avulses off a piece of bone.

24. Musculoskeletal Emergencies Fractures - Depressed
Blunt trauma to flat bone usually associated with significant soft tissue damage
serious group of fractures
usually the result of slow impact with a large solid impact
section of the bone becomes ‘dented’.
Secondary injuries:
laceration of cerebral arteries from bone fragments
neurological complications:
seizure
chronic headaches

25. Musculoskeletal Emergencies Fractures – open vs. closed
Much higher incidence of infection - contaminated
Considered surgical emergency
Can cause significant blood loss
open - formerly known as compound
closed - formerly known as simple fracture
an open fracture occurs when the broken bone punctures the skin
always considered contaminated, prophylactic antibiotics given
sometimes visible on an X-ray
open fractures, whether obvious or subtle, always communicate with the environment.
infection and poor healing are common following open fractures

26. Musculoskeletal Emergencies Fractures - signs & symptoms
Tenderness or pain
Deformity
Decreased mobility
Swelling
Ecchymosis

27. Musculoskeletal Emergencies Fractures - signs & symptoms
Crepitus
Muscle spasm
Inability to bear weight
Decreased or absent pulses
Pallor, shock
pelvic fractures
femur fractures

28. Musculoskeletal Emergencies Fractures - treatment
Immobilize
Remove jewelry or constrictive clothing from injured extremity
remove and secure jewelry or any other item distal or lateral to injury that may create constriction
follow institution procedure
document.

29. Musculoskeletal Emergencies Fractures - treatment
Apply ice to reduce swelling and pain
Elevate extremity above the level of the heart

30. Musculoskeletal Emergencies Fractures
Prepare for:
closed reduction
splinting or casting
If open fracture prepare for surgery
Cover with sterile, saline-soaked dressing
closed reductions are routinely done in the ED utilizing conscious sedation agents
surgical intervention is necessary if closed reduction unsuccessful or open fracture is present

31. Musculoskeletal Emergencies Dislocation & Subluxations
Occurs when a joint exceeds it’s normal range of motion and the articular surfaces are no longer in direct contact.

32. Musculoskeletal Emergencies Dislocation & Subluxations
Result:
Impaired circulation
Ligament injury
Nerve damage
Disruption of muscle insertions

33. Musculoskeletal Emergencies Dislocation & Subluxations
Fracture are often associated with dislocation injuries
Common areas of dislocations include the shoulder, elbow, hip and knee

34. Musculoskeletal Emergencies Dislocation & Subluxations
Signs & Symptoms
Localized pain, moderate to severe
Point tenderness
Joint deformity
Click to next slide for more signs & symptoms

35. Musculoskeletal Emergencies Dislocation & Subluxations
Signs & Symptoms
Decreased or absent range of motion
Edema
Diminished or absent distal pulses and sensation

36. Musculoskeletal Emergencies Dislocation & Subluxations
Interventions:
Keep NPO!
Remove jewelry or constrictive clothing from injured extremity
Apply ice to reduce swelling and pain
Initiate prompt treatment to minimize complications
Why NPO????
conscious sedation required to attempt closed reduction.
closed reduction efforts may fail and patient may end up in operating room
Click to next slide for more interventions

37. Musculoskeletal Emergencies Dislocation & Subluxations
Prepare reduction procedures
Monitor neurovascular status of injured extremity
Immobilize joint post reduction

38. Musculoskeletal Emergencies Nursemaids Elbow
Radial head subluxation
Causes:
lifting by the hand
swinging while holding the hands
pulling arms through the sleeves
catching by the hand to prevent a fall
pulling along when in a hurry
occurs when the radial head slips
common condition in children younger than 4 years of age.
caused by a sudden pull or traction on the hand or forearm.
Symptoms:
immediate pain in the injured arm
refusal or inability to move the injured arm
anxiety, crying

39. Musculoskeletal Emergencies Nursemaids Elbow
Treatment:
Provider manipulation of affected extremity
X-rays not always indicated
Prone to recurrences
treatment consists of provider manipulation of arm so that ligament and radial head return to their normal position.
if successful, a click or snap can be felt at the radial head.
reduction of the elbow, without and x-ray, should not be done if the possibility of fracture or dislocation exists.
x rays are not always obtained when the findings are consistent with nursemaid's elbow
x rays may appear normal even when the radial head is subluxed.
teach parents how to prevent and treat recurrences.

40. Musculoskeletal Emergencies Degloving Injuries
The separation of skin and subcutaneous tissue from the underlying musculofascial planes
external forces shear the skin from underlying tissues.
most frequent affects extremities
severe degloving injuries are classically associated with roller type machinery or vehicle rollovers
can result in tissue necrosis, sepsis, death

41. Musculoskeletal Emergencies Degloving Injuries
Signs & Symptoms
Area of skin is torn away from underlying vascular supply
Pain
Hemorrhage

42. Musculoskeletal Emergencies Degloving Injuries - treatment
Control bleeding
Irrigate and cleanse area
Administer medications and evaluate effectiveness
analgesics
antibiotics
tetanus immunization

43. Musculoskeletal Emergencies Compartment Syndrome
Occurs when increasing interstitial pressure inside the fascial compartment results in neurovascular compromise causing soft tissue damage to the confined space
increased pressure within closed soft tissue compartments can result in serious consequences
elevated compartment pressures commonly follow significant injuries to the forearm and leg and should be diagnosed early with careful monitoring.

44. Musculoskeletal Emergencies Compartment Syndrome
Causes:
Crush injuries
Contusions
Snake bites
Circumferential extremity burns
Onset 4 to 8 hours after injury
most commonly occurs in the lower leg or forearm
onset 4 – 8 hours after injury
can be delayed up to 48 to 96 hours.

45. Musculoskeletal Emergencies Compartment Syndrome
Increasingly severe pain at rest or with passive movement
Tense, swollen area
Diminished sensation
Pain is the earliest and most reliable indicator
(especially with passive movement)
Also:
pallor
paralysis
parasthesia
pulselessness (late sign) are also indicative of elevated pressures.

46. Musculoskeletal Emergencies Compartment Syndrome
Progressive loss of muscle or motor function
Loss of pulses (late sign)
Increased compartment pressures

47. Musculoskeletal Emergencies Compartment Syndrome
Interventions:
Maintain extremity in neutral position, at the level of the heart.
Must not be left dependent

48. Musculoskeletal Emergencies Compartment Syndrome
Remove all casts, splints or appliances
Assist with obtaining compartment measurements
Monitor extremity perfusion every 15 minutes
Click to next slide for more interventions

49. Musculoskeletal Emergencies Compartment Syndrome
Prepare for surgical release of affected area
Fasciotomy
If untreated can result in irreversible tissue necrosis and paralysis

50. Case Scenario
Which of the following is not a symptom of compartment syndrome?
pain upon passive movement
petechiae
paraesthesia of the affected extremity
decreased capillary filling time
Click to next slide for answer

51. Case Scenario petechiae
Which of the following is not a symptom of compartment syndrome?
pain upon passive movement
petechiae
paraesthesia of the affected extremity
decreased capillary filling time

52. Case Scenario
Which of the following findings indicates successful reduction of nursemaid’s elbow?
the arm is immobile
the radial pulse is strong
the elbow moves freely
the patient cries when the arm is examined
Click to next slide for answer

53. Case Scenario the elbow moves freely
Which of the following findings indicates successful reduction of nursemaid’s elbow?
the arm is immobile
the radial pulse is strong
the elbow moves freely
the patient cries when the arm is examined

54. Finished!
Questions?