Chapter 13

Musculoskeletal Injuries

Musculoskeletal Injuries

Rarely life-threateningCan have serious consequences and

permanent disability if not recognized or care for properly

Mechanism of injury is an important clue as to what injuries may be present

Definitions

Fracture A break in the continuity of bone

• May be complete, with ends widely separated or incomplete with a hairline crack

• May be open or closed

Sprains Injuries to ligaments

• Usually from stretching forces

Definitions

Strains Injuries to muscles or tendons

• Usually from over stretching or violent contractions

Dislocations Displacement of bones in a joint from their

normal anatomical positions.• Stretching or tearing of ligaments must also take

place

Prehospital Care

A painful, swollen, deformed extremity is treated as if a significant bony or soft tissue injury has occurred

Mechanisms of Injury

Forces Direct Indirect Twisting Violent muscular contractions Pathological

Bone & Joint Injuries

Open and Closed Injuries Closed or simple fractures

• Displaced (angulated) or non-displaced Open or compound fractures

• Can result from– penetrating wounds

– lacerations from crush injuries

– sharp bone fragments tearing through the soft tissue

• Can be displaced or non-displaced

Signs and Symptoms

Pain and Tenderness Most common

• Often only signs of fracture

• Point tenderness or guarding

• Pain may be referred distal or proximal to the injury site

Deformity or Angulation Protuberance of bone end against soft tissues Overriding or separation of bone fragments

Signs and Symptoms

Swelling and Discoloration Can be an early sign or may not be apparent for

several hours• Always remember to do a bilateral comparison

• Initially may be redden, ecchymosis may appear quickly or be delayed

Loss of Motion Can result from pain on attempted movement or gross

disruption of area• Never attempt to force movement

Less Common Signs and Symptoms

Grating or Crepitus• Sound or sensation

• Do Not attempt to elicit this finding

Exposed Bone• Obvious sign of an open fracture

Loss of Distal Pulse or Sensation• Numbness and/or tingling

• False Motion

Involuntary Muscle Spasms

Dislocations

Complete or Partial Can result from direct or indirect forces Can be associated with a fracture Signs specific to dislocations include:

• Loss of motion

• Deformity at joint

• Joint locked into position

• Pain & swelling over joint

Care of Musculoskeletal Injuries

Perform Scene Size-upInitial Assessment

Use Appropriate Body Substance Isolation Do not become distracted by grotesquely

angulated or deformed extremities Life-threatening conditions ALWAYS come first

• Direct attention to extremities after managing life-threatening conditions and after stabilization of spinal injuries

Care con’t.

Detailed Exam Carefully cut away clothing to expose injury

site Use DOTS (deformity, open injuries, trauma

and swelling) or DCAP/BTLS (deformities, contusions,

abrasions, punctures/burns, tenderness, lacerations and swelling)

Care con’t.

Administer oxygenDress open woundsTreat for shockApply cold packs (if applicable) to reduce

swelling and painSplint (as necessary to your situation) and

elevate following splitting if applicable

Splinting

Rationale for Splinting Reduces pain Prevents further injury

• Bleeding (average blood loss with a closed fracture)– Radius & ulna 150-250 ml

– Humerus 250 ml

– Pelvis 1500-3000 ml

– Femur 1000 ml

– Tib/Fib 500 ml

Splinting

General Rules

Immobilize Critical Patient with a Spine Board When in Doubt, Splint Splint Prior to Moving Pad Splints (Remove Clothing) Immobilize Above & Below Injury

Splinting con’t.

General Rules con’t.

Check & Recheck Neurovascular Function Cover Open Wounds Treat Protruding Bones Splint in Position Found Severe Deformities

Splinting

Types Rigid Soft Sling and Swathe Improvised Air Splints

Application In Lab

Specific Musculoskeletal Injuries

BonePossible Signs &Symptoms Treatment

Clavicle Obvious deformity Sling & swatheShoulder Dropped shoulder, arm

held to chest, loss of contourSling & swathe

Humerus Obvious deformity,swelling, limited motion

Rigid splint, sling &swathe

Elbow Obvious swelling, deformity Rigid splint & sling& swathe

Radius/UlnaWrist

Deformity Rigid splint, slingand swathe

Hand Deformity, loss of function Position of function,rigid splint, sling &swathe

Specific Musculoskeletal Injuries

BonePossible Signs &Symptoms Treatment

Pelvis Pain, shock, mobility ofpelvic ring oncompression

Spine board

Dislocated Hip Pain & locked joint Legs together withsupport, spine board

Hip Injury Shortened & externallyrotated extremity

Same

Femur Swelling, deformity, signsof shock

Isolated mid-femur,traction splint;

Knee Deformity, locked,unstable

Rigid, position found

Tib/Fib Deformity Rigid splintAnkle/Foot Pain, deformity Soft splint

Head and Spinal Injuries

~ 2 Million Head and Spinal injuries Yearly Which Are Serious Enough to Require Medical Attention 80,000 permanently disabled

• ~48% from MVAs

• ~21% from Falls

• ~14% from Sports

• ~15% from Acts of Violence

• ~2% Other

Head and Spinal Injuries

Should Be Considered Serious If: Fall from a height equal to or greater than own

height Diving mishap (hitting board or diving into

shallow water) Unconsciousness for unknown reason Blunt force trauma to the head, trunk or pelvis Gunshot wound penetrating the head or trunk

Head and Spinal Injuries

Seriousness con’t. Motor vehicle accident where person is

unrestrained and has impact with windshield Thrown (from vehicle, motorcycle, horse, etc. Broken helmet (motorcycle, bicycle, football,

industrial) Lightening strike Unconscious in water 5 feet or less in depth

Spinal Injuries

Signs and Symptoms Point tenderness Pain with movement (Do Not have patient

attempt movement) Paralysis of arms &/or legs

• Numbness, tingling, weakness• Loss of sensation

Significant trauma to head, shoulders, back, abdomen, pelvis

Spinal Injuries

Signs and Symptoms con’t. Intermittent pain along spine, down legs Bruises, cuts or edema along the spine Respiratory distress Shock Unresponsiveness Incontinence Priapism

Head Injuries

Signs and Symptoms (may be obvious immediately or develop over time) Alternating level of consciousness Slow, bounding pulse Deformity (can be obvious) (rare) Penetrating injury Blood or CSF from the nose or ears Raccoon eyes Battle’s sign

Head Injuries

Signs and Symptoms con’t. Cushing’s syndrome (B.P.-up, Pulse-down) Nausea, vomiting Visual disturbances

• Doll’s eye response, Unequal or unreactive pupils Headaches Irregular or abnormal respiratory patterns

• Cheyne-Stokes, Ataxic Respirations, Apneustic Respirations, Diaphragmatic Respirations

Head Injuries

Signs and Symptoms con’t. Seizures Personality changes

• Combative or aggressive Auditory disturbances

• Ringing

• Equilibrium problems (Do Not Test) Posturing

• Decorticate or Decerebrate

Head and Spinal Injuries

General Rule of Thumb If mechanism of injury exerts great force to the

upper body or if there is soft tissue damage to the head, face or neck due to trauma, assume there is a possible cervical spinal injury.

Any unconscious patient who is the victim of an accident must be cared for as a spinal injury patient.

Head and Spinal Injuries

Assessment and Care Minimize movement A, B, C’s with in-line stabilization Control external bleeding Maintain body temperature Ongoing assessment every 5 minutes Oxygen if available

Chest Injuries

Signs and Symptoms Pain at injury site Pleurisy Dyspnea Inadequate or unequal chest expansion Hemoptysis Cyanosis Weak, rapid pulse

General Principles of Care

Secure and maintain airway (modified jaw thrust)

Control external bleedingCover penetrating/perforating woundsReassess patient every 5 minutes

Specific Injuries

Rib Fractures Common injury 4-9 (5-10) most common Patient often leans toward injured sign Multiple fractures (Flail chest)

• 2 or more ribs with 2 or more fracture points

• Watch for paradoxical breathing

Specific Injuries

Penetrating Chest Injuries Pneumothorax Tension Pneumothorax Spontaneous Pneumothorax Hemothorax Sucking Chest Wound Pericardial Tamponade

• Narrowing of systolic & diastolic pressure readings

• JVD (jugular vein distention)

Specific Injuries

Compression Injury Complications Pulmonary Contusion

• Most commonly from blunt trauma Myocardial Contusion

• Not detectable in the field

Abdominal Injuries (Blunt and Penetrating)

Signs and Symptoms Bruising

Imprint marks, Entry & exit wounds B.P. down, pulse up, shock Local or diffuse abdominal tenderness, referred

pain Abdominal distension, Nausea and/or vomiting Evisceration Other signs/symptoms of bleeding or shock

Assessment and Care

Leave in position found if possible If evisceration present, lie patient supine with knees

slightly flexed and supported

Inspect for entry and exit woundsControl external bleeding, stabilize impaled

objects, treat for shockEviscerations

Do Not replace organs, cover with an occlusive dressing, keep patient warm