Principles of Musculoskeletal Injuries

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Chapter 24

• Principles of Musculoskeletal Injuries

2
Objectives (1 of 3)

• Describe the function of the muscular system.
• Describe the function of the skeletal system.
• List the major bones or bone groupings of the
  spinal column, the thorax, the upper
  extremities,and the lower extremities.
• Differentiate between an open and closed painful,
  swollen, deformed extremity (fracture).

3
Objectives (2 of 3)

• State the reasons for splinting.
• List the general rules for splinting.
• List the complications of splinting.
• Explain the rationale for splinting at the scene
  versus load and go.

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Objectives (3 of 3)

• Demonstrate the emergency care principles for
  injured extremities.
• Demonstrate the basic principles of applying the
  three basic splint types rigid fixation, soft
  fixation, and traction splints.

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Anatomy and Physiology of the Musculoskeletal
System
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Types of Muscle

• Skeletal muscles
• Attach to bone by tendons
• Voluntary
• Smooth muscles
• Involuntary
• Cardiac muscle
• Specialized and has separate regulatory systems

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Skeletal System
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Joints

• A joint is formed wherever two bones come into
  contact.
• Ligaments hold bones together.
• Articular cartilage allows bone ends to glide
  easily.
• Joints are lubricated by synovial fluid.

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Types of Musculoskeletal Injuries

• Fracture
• Broken bone
• Dislocation
• Disruption of a joint
• Sprain
• Joint injury with tearing of ligaments
• Strain
• Stretching or tearing of a muscle

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Mechanism of Injury

• Force may be applied in several ways
• Direct blow
• Indirect force
• Twisting force
• High-energy injury

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Fractures

• Closed fracture
• A fracture that does not break the skin
• Open fracture
• External wound associated with fracture
• Nondisplaced fracture
• Simple crack of the bone
• Displaced fracture
• Fracture in which there is actual deformity.

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Greenstick Fracture
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Comminuted Fracture
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Pathologic Fracture
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Epiphyseal Fracture
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Signs and Symptoms of a Fracture (1 of 2)

• Deformity
• Tenderness
• Guarding
• Swelling
• Bruising

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Signs and Symptoms of a Fracture (2 of 2)

• Crepitus
• False motion
• Exposed fragments
• Pain
• Locked joint

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Signs and Symptoms of a Dislocation

• Marked deformity
• Swelling
• Pain
• Tenderness on palpation
• Virtually complete loss of joint function
• Numbness or impaired circulation to the limb and
  digit

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Signs and Symptoms of a Sprain

• Point tenderness can be elicited over injured
  ligaments.
• Swelling and ecchymosis appear at the point of
  injury to the ligaments.
• Instability of the joint is indicated by
  increased motion.
• Pain

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Assessing Musculoskeletal Injuries (1 of 2)

• Assess mechanism of injury.
• Perform initial assessment.
• Perform focused physical exam.
• Follow BSI precautions.
• Give oxygen if needed.
• Follow DCAP-BTLS.

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Assessing Musculoskeletal Injuries (2 of 2)

• If patient critically injured, arrange for
  immediate transport.
• Be alert for compartment syndrome.
• Splint injury.
• Transport.
• Monitor neurovascular status during transport.

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Evaluating Neurovascular Function

• Examination of the injured limb should include
  assessment of the following
• Pulse
• Capillary refill
• Sensation
• Motor function

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Severity of Injury

• Critical injuries can be identified using
  musculoskeletal injury grading system.
• Refer to Table 24-1 on page 587.

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Emergency Medical Care

• Completely cover open wounds.
• Apply appropriate splint.
• If swelling is present, apply ice or cold packs.
• Prepare patient for transport.
• Always inform EMS about wounds that have been
  dressed and splinted.

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Splinting

• Use a flexible or rigid device to protect
  extremity.
• Injuries should be splinted prior to moving the
  patient, unless patient is critical.
• Splinting helps prevent further injury.
• Improvise splinting materials when needed.

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General Principles of Splinting (1 of 3)

• Remove clothing from the area.
• Note and record patients neurovascular status.
• Cover all wounds with a dry, sterile dressing.
• Do not move patient before splinting.

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General Principles of Splinting (2 of 3)

• Immobilize the bones above and below the injured
  joint.
• Pad all rigid splints.
• Maintain manual immobilization.
• Use constant, gentle, manual traction if needed.
• If you find resistance to limb alignment, splint
  the limb as is.

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General Principles of Splinting (3 of 3)

• Immobilize all suspected spinal injuries in a
  neutral in-line position.
• If the patient has signs of shock, align limb in
  normal anatomic position on a backboard and
  transport.
• When in doubt, splint.

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Rigid Fixation Splints

• Firm material applied to fractures that prevent
  motion
• Quick splints
• Cardboard
• Wire and ladder splints
• SAM splint

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Soft Fixation Splints

• Air splints
• Vacuum splints
• Sling and swathe
• Blanket/pillow splints

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Applying a Quick Splint (1 of 2)

• Open the quick splint.
• Assess distal CMS functions of the leg.
• Manually stabilize leg by grasping foot and leg
  behind and below the knee.
• Slight longitudinal traction can be used.
• Elevate the extremity carefully.
• The pant-leg pinch lift can also be used.

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Applying a Quick Splint (2 of 2)

• Have second rescuer slide the open splint under
  the leg.
• Lower leg carefully into splint.
• Second rescuer can fold sides of splint and
  secure straps, cords, etc.
• Reassess distal CMS functions of the leg.

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Applying a Sling and Swathe (1 of 2)

• Assess distal CMS functions.
• Carefully bend injured arm to just lt 90 and lay
  a cravat on the chest under the arm, with a 90
  point at the elbow.
• Bring lower end up and over shoulder on injured
  side.
• Bring upper end over opposite, uninjured shoulder
  and tie at side of neck.

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Applying a Sling and Swathe (2 of 2)

• Secure a second cravat, 3 to 6 wide, around the
  chest and injured upper arm.
• To avoid pressure on the injured shoulder,
  alternately, bring lower end through injured
  arms armpit and tie it over the scapula.
• Reassess distal CMS functions.

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Applying a Blanket Roll (1 of 2)

• Fold blanket longitudinally into thirds.
• Lay two or three cravats near end of blanket and
  roll firmly.
• Assess distal CMS functions.

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Applying a Blanket Roll (2 of 2)

• Position roll snugly under injured shoulder tie
  one cravat over uninjured shoulder. Secure
  other(s) around chest and/or waist.
• Secure injured arm with sling and swathe.
• Reassess distal CMS.

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Applying a Vacuum Splint

• Stabilize and support injury.
• Place splint and wrap it around limb.
• Draw air out of splint and seal valve.
• Check and record distal CMS functions.

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Improvised Splints

• Use rigid or semi-rigid materials. Examples
• Skis, ski poles
• Boards, branches
• Blankets, pillows, camping pads
• Shovels, probes, ice axes
• Uninjured part, ie, finger, leg, chest wall

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In-line Traction Splinting

• Act of exterting a pulling force on a bony
  structure in the direction of its normal
  alignment.
• Realigns fracture of shaft of a long bone.
  Usually used for femur fractures.
• Use the least amount of force necessary.
• If resistance is met or pain increases, splint in
  deformed position.

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Traction Splints

• Do not use a traction splint under the following
  conditions
• Upper extremity injuries
• Injuries close to or involving the knee
• Pelvis and hip injuries
• Partial amputation or avulsions with bone
  separation
• Lower leg or ankle injuries

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Applying a Traction Splint (1 of 3)

• An angulated fracture will need to be realigned
  before a splint can be applied.
• Manually stabilize fracture site.
• Expose site and care for any open wounds.
• Per local protocol, remove footwear and assess
  distal CMS functions.

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Applying a Traction Splint (2 of 3)

• Prepare splint for application.
• Smoothly realign fracture and maintain traction.
• Fasten ankle hitch.
• Support fracture and transfer traction to ankle
  hitch.
• Position splint pad and secure ischial strap.

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Applying a Traction Splint (3 of 3)

• Carefully transfer traction to splint.
• Secure splint to leg.
• Reassess distal CMS functions.
• Logroll patient onto backboard and secure.

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Applying a Sager Traction Splint (1 of 2)

• Manually stabilize fracture.
• Assess distal CMS functions.
• Expose site and care for any open wounds.
• Adjust thigh strap.
• Estimate proper splint length.
• Arrange ankle pads to fit.
• Place splint along inner aspect of thigh.

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Applying a Sager Traction Splint (2 of 2)

• Secure ankle harness.
• Snug cable ring against bottom of foot.
• Pull out inner shaft of splint to apply traction.
• Secure splint to leg.
• Secure patient to backboard.
• Reassess CMS function.

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Hazards of Improper Splinting

• Compression of nerves, tissues, and blood vessels
• Delay in transport of a patient with a
  life-threatening condition
• Reduction of distal circulation
• Aggravation of the injury
• Injury to tissue, nerves, blood vessels, or muscle

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Improvised Traction Splints

• Single-ski technique
• Pre-made pockets
• Cravats
• Two ski poles
• Two paddles
• Scoop stretcher

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Ski Boot Removal (1 of 2)

• Guided by local protocol.
• Many factors can influence protocol.
• Transport time
• Injury
• Type of splint used
• CMS status
• Boot should be removed before patient arrives at
  hospital.

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Ski Boot Removal (2 of 2)

• Stabilize lower leg.
• Loosen all buckles, straps, and laces.
• Spread boot shell and pull out boot tongue.
• Apply tension to back of boot and pressure to
  boot toe with shoulder.
• Rotate the boot off the foot.
• Monitor for pain. Modify as needed.
• Assess distal CMS functions and splint.