1. Musculoskeletal Injuries
Chapter 20, Section 1
Musculoskeletal Injuries

3. 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

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, 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

6. 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.

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 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

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

10. 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

11. 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

12. Common Musculoskeletal Injuries
Sprain
Stretching or tearing of a ligament
Tears may need surgery
Joint is displaced beyond its normal alignment
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13. 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.
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14. 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
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15. 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

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

17. Types of Fractures
Types of fractures.

18. Butterfly and Impacted

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, 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.
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21. 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)

22. 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

24. 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

25. 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.

26. 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.
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27. 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

28. 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.

29. 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.

30. 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.
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31. 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

32. 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

33. 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.
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34. 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

35. 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

36. 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.

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 transport
Prevent paralysis in spinal injuries
Discussion Point:
Mention each as this is mostly straightforward material.

39. 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.
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40. 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)
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41. 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.

42. 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

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.
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44. 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.