Musculoskeletal Injuries
June/July 2013 CE
Condell Medical Center
EMS System
Site Code: 107200E-1213
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
1
Objectives
Upon successful completion of this
program the EMS provider will be
able to:
Describe anatomy and physiology of the
musculoskeletal system.
Discuss the effects of aging on the
musculoskeletal system.
Describe the pathophysiology of strains,
sprains, dislocation, and fractures.
2
Objectives cont’d
Describe the assessment of the
musculoskeletal system.
Discuss interventions and
management of musculoskeletal
system injuries.
Discuss pain management based on
the Region X SOP’s.
3
Objectives cont’d
Describe compartment syndrome,
presentation, and intervention in the
field.
Actively participate in case scenario
discussion.
Actively participate in application of
a variety of immobilization devices
including the HARE traction splint or
Sager and KED device.
Successfully complete the post quiz with
a score of 80% or better.
4
Musculoskeletal Injuries
Common group of injuries
Many injuries are isolated
Few are life threatening
Many can affect quality of life if just
temporarily
5
Function of Musculoskeletal
System
Gives body its shape
Protects internal organs
– Can also cause injuries to those same
organs
Allows for movement
– Usually performed by muscles
Storage system for salts and
minerals used in the body
Produces red blood cells used for
oxygen transport
6
Control of Musculoskeletal System
Under control of the brain and
nervous system
Skeletal muscle is voluntary muscle
Can be contracted and relaxed at the
will of the individual
– Walking, sitting
– Swallowing, smiling
– Talking
– Performing activities of daily living
7
A & P Musculoskeletal System
A bony framework making up the skeleton
System held together by ligaments
– Ligaments connect bone to bone
System held together by layers of muscles
– Tendons connect muscles to bones
– Skeletal muscles are voluntary
Includes additional connective tissue
– Example: cartilage
8
Joints
May be movable or immovable
Movement direction includes
– Flexion
– Extension
– Abduction
– Adduction
– Pronation
– Supination
9
Pathological Fractures
Fractures resulting from a disease
that causes degeneration and
weakening of a bone making it prone
to fracture
Fracture often occurs with little
provocation; minimal force
Often occurs in the presence of a
diagnosis of cancer
10
Effects of Aging
Decreased flexibility
Decreased range of motion
Loss of balance
Osteopenia – loss of bone mineral density;
softening of bones
Osteoporosis – degenerative bone disorder
with loss of bone density making bones
brittle and fragile
– Weakened bones more susceptible to
fracturing
– More common in women than men but affects
both populations
11
Counteracting the Effects of Aging
Stay active
Strengthen your core
– Helps with balance
Continue weight bearing exercises
– Cardiovascular exercise strengthens
your heart
– Strength training builds bone and
muscle strength
12
Mechanism of Injury
Determining mechanism of injury can help
determine area of injury and may point to
the extent of injury suffered
Forces divided based on MOI
– Direct – a direct blow
i.e.: knees hit dashboard in MVC injuring the knee
– Indirect – force impacts one end of limb and
damage transmitted to a distant point
i.e.: fall on outstretched arm resulting in fractures of
the wrist and clavicle
– Twisting – one part of extremity stationary while
the rest twists
i.e.: sliding on ice, at end of ice patch the foot stops 13
but the body remains in motion and rolls over the foot
Can you tell what the injury is???
No, not always without more diagnostics
– Most musculoskeletal injuries are treated the
same regardless of the final diagnosis
So…
– Why do you need to know the difference between
a sprain and a dislocation or fracture???
Because…
– As a professional, you should be able to use
critical thinking skills
You might be able to fine tune treatment based on
mechanism of injury and your impression
14
Strains
Injury to a muscle or muscle and
tendon
Often caused by overextension or
over stretching
Muscle fibers tear
Pain is typical to that experienced
from over muscle use
Often no swelling or discoloration
because there is no bleeding
15
Sprains
Injury to the joint capsule with
damage to or tearing of the
connective tissue
Usually involves ligaments
Most vulnerable are shoulder, knee
and ankle joints
Typically immediate pain and
tenderness followed by swelling and
eventually discoloration
– Can be more swollen and more painful
than some fractures
16
Dislocations
Significant injury
Displacement of bone from its
normal position in a joint
– Joint usually forced beyond normal
range of motion
Can cause damage to blood vessels
and nerves by compression or
tearing
– Need treatment sooner than later
17
Dislocation
Typical appearance
– Joint found in abnormal appearance
with deformity and possible swelling
– Pain and tenderness present
– Inability to move extremity
Not recommended to manipulate
dislocations but to splint in position
found
– Loss of distal pulses increases the
severity of the injury
18
Fractures
Loss of continuity of the structure of
a bone
Sharp fragments may injure
surrounding tissue
Arteries and bones run throughout
the bones
– Vessels within the bone may tear or
rupture and bleed
19
Fractures cont’d
Classified as open or closed
– Open is associated with an open wound to the
skin
The wound may be from the outside inward
(i.e.: the mechanism of injury from a
missile) or from the bone end poking
through skin
Displaced bones more likely to damage
surrounding nerves, blood vessels,
muscles, ligaments, and tendons
20
Critical Fractures
Femur and pelvis
– Potential for significant blood loss and
development of hypovolemic shock
– Goal – immobilize bony injury AND reduce
potential blood loss
Bones tend to bleed when injured AND exposed bone
ends could lacerate near by vessels
Potential blood loss
– Each femur – 1500 ml blood loss
– Pelvic fracture – 2000 ml blood loss
21
Critical Conditions
Pulselessness or cyanosis
– Immobilize extremity
– Provide expedited transport
Note: Limb threatening
musculoskeletal injuries take a back
seat to life threatening injuries
– If there is no time to immobilize an
orthopedic injury, placing the patient on
a backboard allows some immobilization
22
Absence of Distal Pulses
Check capillary refill, skin
temperature/color and general condition
– If pulses found, mark site with an “x” to help
find the same pulse site on reassessment
Continue to check for sensation and
movement
Provide rapid transport
Splint extremity in position found
Document assessment and care provided
23
General Patient Presentation
Common presentations of most
musculoskeletal injuries
Pain
Swelling
Decreased or lack of movement
Inability to bear weight
Possible deformity
Occasionally blood loss (i.e.: femur,
pelvis
24
Assessment of Musculoskeletal
System
Assessment before and after
splinting
Assess pulses (can compare to
opposite side)
Evaluate motor capability
– Can you wiggle fingers/toes
Evaluate sensory status
– Can you feel me touching fingers/toes?
Call it what you want:
– PMS – CMS - SMV
25
Management of Musculoskeletal
Injuries
RICE
– Rest
– Ice application to reduce swelling
– Compression with ACE wrap to reduce
swelling
– Elevation to reduce swelling
Reducing swelling reduces the pain
level
Pain control with medication
Distraction
26
Region X Pain Management
Same formula for adults and peds
Fentanyl 0.5 mcg/kg IVP/IN/IO
May repeat same dose in 5 minutes
Max total dose 200 mcg
27
Fentanyl
Synthetic opioid narcotic
Used for analgesic purposes
Properties similar to morphine with
less cardiovascular side effects
Administer over 2 minutes IVP/IN/IO
Watch for respiratory depression,
bradycardia
28
Fentanyl cont’d
Onset - immediate
Peak effect – 3 – 5 minutes
Duration 30 - 60 minutes
IN route used in absence of IV
access
– Administer in divided doses
– IN route onset 2 minutes
29
Narcan® (Naloxone)
Narcotic antagonist
– Competes for opiate receptor sites in brain
– Reverses effects of narcotics including
synthetics
– Onset within 2 minutes
Dosing- enough to improve ventilations
– Adults 2 mg IVP/IN/IO
– Peds > 20 kg – 2 mg
– Peds < 20 kg – 0.1 mg/kg
30
Narcan cont’d
Side effects are rare BUT
– Can cause narcotic withdrawal in
narcotic dependent person
May present with seizures after
administration
Effects may not last as long as the
narcotic you are countering
– Watch for relapse of level of
consciousness and respiratory effort
31
Compartment Syndrome
Complication usually associated with
closed injuries to extremities
Major muscle groups contained in
compartments surrounded by inelastic,
non-expanding fascia
Pressures usually around 0
Pressures over 30 mmHg can restrict
capillary blood flow
Irreversible ischemic damage usually
occurs at about 10 hours
32
Compartments of the Leg
33
Compartment Syndrome
There is excessive swelling in an
enclosed space and that space has
expanded to full capacity with no
more room to expand
– Skin can only be stretched so far
High pressures impede blood flow
and leads to hypoxia of tissues
Hypoxic tissues trigger leakiness of
capillaries causing further swelling
34
Compartment Syndrome
Assessment
Develops over time most likely after 6-8
hours
– Not usually seen in the field immediately after
the insult
History in recent past of an injury
Prevalent symptom – pain out of
proportion; pain with passive stretching
– Typically a deep, burning pain
– Pain not affected by positioning
Motor and sensory usually normal
Distal pulses usually present
35
Compartment Syndrome
Intervention
In the field, care for the underlying injury
– Splint and immobilize all potential fractures
– Apply cold packs as needed
– Elevate injured extremity
Reduces edema
Increases venous return
Lowers compartment pressure
Note: Care may differ in the hospital;
limited resources available in the field
36
Immobilization Devices
Goal – to prevent further injury that
could be caused by movement
Reduces stress on ligaments,
muscles, and tendons
Reduces pain by reducing limb
motion
37
Golden Rule of Immobilization
Immobilize the joint above and the joint
below the injury
When applying a splint that wraps an
extremity, wrap from a distal to more
proximal point
– This prevents trapping of blood distal to the
injury
– Don’t wrap so tight as to impede blood flow
Evaluate distal circulation, motor function,
and sensation before and after splinting
– Document findings
38
Traction Splints
Proximal femur fractures (surgical
neck and intertrochanteric fractures)
frequently caused by hip injuries,
transmitted forces, or aging
– Referred to as hip fractures
– Do not benefit from traction splints
If a joint injury is suspected, traction
splints should not be used
39
Traction Splints
Purpose
– Relieve the spasm
– Relieving spasm decreases the pain
Note:
– Rapid transport for life threatening
condition takes priority over placing
splints on a patient
Immobilization using a full backboard may
be the best you can do in those situations
40
HARE Traction
For suspected mid-shaft femur
fractures
41
HARE Traction Steps
1 rescuer maintains manual traction
to foot
2nd rescuer assesses distal
CMS/PMS/SMV
2nd rescuer prepares traction device
– Place device next to uninjured leg
– Place pad at ischial crest
– Adjust length to extend past foot
– Tighten locking collars
42
HARE Traction Steps cont’d
– Open & position velcro straps
– Open ratchet & extend traction strap
– Place splint next to injured leg
– 2nd rescuer applies ankle hitch & takes
over applying firm, gentle manual traction
via ankle hitch
– 1st rescuer moves
splint
into position
firmly
against
ischial
tuberosity
43
Ischial Tuberosity
Most distal part of the bony pelvis
The shape forms the platform for
sitting when upright
– Structured to support the body’s weight
when sitting
44
HARE Traction Steps cont’d
– 1st rescuer secures proximal, pubic strap
high over the thigh
– 1st rescuer attaches ankle hitch to
traction splint
– Traction strap tightened until pain &
spasm are relieved and stopped when
leg lengths are equal
Manual traction stops when mechanical
traction takes over and is effective
45
HARE Traction Steps cont’d
– Remaining straps secured in place
Avoid placing a strap across injury site and
knee
– Support distal traction stand on
backboard
Backboard most likely will need to be shifted
towards foot end of cot and extend off of cot
to support traction stand
– Reassess distal CMS/PMS/SMV after
splinting
– Document assessment findings and
procedure
46
Sager Splint
Alternative device for suspected
femur fractures
47
Sager Splint cont’d
Place splint between patient’s legs
along medial aspect of injured leg
with pulley towards the injured leg
Snuggly wrap the ankles with the
ankle harness provided
Pull control tabs to engage ankle
harness tightly against crossbar
Grasp the padded shaft of splint with
one hand and red traction handle
with the other
48
Sager Splint cont’d
Gently extend the inner shaft until
desired traction is achieved
– Suggested is 10% of patient weight up
to 7kg (15#) per leg for unilateral
fractures (14 kg (30#) bilateral
fractures)
Apply remaining straps for a snug fit
Apply figure 8 straps around feet to
prevent rotation
Recheck distal CMS/SMV/PMS
49
KED Device
When extrication does not need to be
emergent
– It takes time and resources to apply
50
KED Device cont’d
KED slid into position behind the
patient
– Manual head immobilization maintained
Middle torso strap applied
Bottom torso strap secured
Leg straps are secured
– Can be criss-crossed or fastened to
same side
– Avoid criss-cross if groin injury present
Now pad void between head and
device and secure head
51
KED Device cont’d
Just prior to moving, top torso strap
is secured
– Not done earlier to prevent restriction or
interference of breathing
Note:
– Secure torso prior to securing the head
Secure the forehead strap running
strap in a downward direction
Secure the chin strap over the
cervical collar
52
KED Device
53
KED Device
To remove patient from vehicle, grasp the
side handles to pivot/tilt/lift the patient
Grasp the side handles and under the
patient’s knees to raise them enough to
slide a backboard under them
Once patient is extricated and on cot,
loosen top strap to allow for chest
expansion
Loosen groin strap for legs to straighten
Readjust remaining straps as necessary
for transport
54
KED Device
Lightly scrub to remove gross
contaminant after each use
Disinfect after each use
Allow to air dry prior to placing in the
storage bag
55
Case Scenario Review
Review the following cases
Determine your general impression
Determine your treatment approach
based on presentation and signs and
symptoms
Discuss methods to reduce pain
56
Case Scenario #1
Your patient is an 89 year-old female
who fell onto an outstretched hand
You note deformity to the wrist
VS: B/P 140/92; P – 92; R – 18
Pain 6/10
57
Case Scenario #1
What is important to ask this patient
with regards to her injury?
For any patient who fell, important to
ask WHY they fell
– If patient was dizzy, consider a cardiac
problem until proven otherwise
Document reason for the fall
58
Case Scenario #1
Patient has a wrist injury from a fall
Based on mechanism of injury (MOI),
what else should be assessed?
– Evaluate up the extremity to points
distal to the injured site
Upper extremity – evaluate fingers to
shoulder including clavicle
Lower extremity – evaluate toes to
hip
59
Case Scenario #1
What is standard assessment for
orthopedic injuries?
– Evaluate distal CMS/PMS/SMV before
and after splinting
What is standard treatment for
orthopedic injuries?
– RICE
Rest - immobilize
Ice – not directly applied over site
Compression – wrap with an ACE
Elevate - higher than heart for swelling
60
Case Scenario #1
How would you address this patient’s
pain?
– RICE
Rest, ice, compress, elevate
– Fentanyl 0.5 mcg/kg IVP/IN/IO
Can repeat same dose in 5 minutes if
needed
Max total dosing is 200 mcg
Watch for respiratory depression with this
synthetic narcotic
61
Case Scenario #2
You respond to a sports complex for
a 17 year-old injured
They planted their foot and then
rolled/twisted their leg
There is obvious deformity to the
ankle/foot
VS: B/P 118/70; P – 82; R – 18
Pain 9/10
62
Case Scenario #2 - MOI
63
Case Scenario #2
What would be your initial
assessment?
– MOI
– Appearance
– Distal CMC/SMV/PMS before and after
splinting
– Level of pain
What is your treatment?
– RICE
– Immobilize in position found
64
Case Scenario #2
How would you address the pain in
this 17 year-old?
– RICE is used
– Follow Peds Pain Management SOP
Same as the adult SOP
Fentanyl 0.5 mcg/kg IVP/IN/IO
– May repeat same dose in 5 minutes is
needed
– Max total doses is 200 mcg
– Watch for respiratory depression
65
Case Scenario #2
17 year-old patient states he does
not want to be transported
What would you do?
– As a minor, this patient cannot give
medical direction or sign a release
– Contact the parents
If unable to contact the parents, transport
the patient to the closest appropriate facility
– Provide explanation to the patient why
you must transport
66
Case Scenario #3
25 year-old male fell off a ladder
while cleaning gutters
The patient is unconscious
– GCS 2/2/4 (total 8)
There is obvious deformity of the
right femur as you approach
– The patient has multiple abrasions and
contusions
– There is blood draining from one ear
67
Case Scenario #3
VS: B/P 110/70; P – 88; R 16
– B/P 120/82; P – 72; R – 24
– B/P 152/78; P – 64; R – 20
What is your impression?
– Multiple trauma
Head injury with orthopedic injuries
– VS indicate increasing intracranial
pressure
What category trauma is this?
Category I
– Transport to highest level trauma center
within 25 minutes
68
Case Scenario #3
Would you take the time to apply a
HARE or Sager to this injury?
– No, life threats are treated over limb
threats
– Placing a patient on the backboard will
need to serve as a splint
HARE or Sager splints can be applied later
as there is time and resources
69
Case Scenario #3
You are unable to start a peripheral IV on
this patient
What would you do?
– Place an IO
As fluid is infusing, the patient becomes
agitated and tries to reach for the IO site
– What would you do?
Administer Lidocaine via the IO for pain control
– Think 50-60-60
– Lidocaine 50 mg over 1 minute and wait 1
minute to resume infusion
70
Case Scenario #4
Your 45 year-old patient injured their
knee falling
VS: B/P 128/86; P – 86; R – 16
Pain 5/10
71
Case Scenario #4
You are unable to palpate distal
pulses on the injured side
What would you do?
– Compare circulation to opposite side
– Contact Medical Control with the finding
– Splint the injury as found
– If pulses are found, mark the site with a
pen
Makes it easier to find the pulse site on
reassessment once found
72
Case Scenario #4
What do you do if loss of distal
pulses?
– Splint in position found
– Notify receiving hospital of condition
– Continue to monitor and assess the
distal CMS/SMV/PMS status
– Do not manipulate injuries without
contacting Medical Control first
– Document findings and interventions
73
Case Scenario #5
How do you care for an open wound?
74
Case Scenario #5
Can irrigate with normal saline for
gross contaminant
Cover wound with moist sterile saline
dressing
– Cover with dry dressing
– Immobilize extremity
Assume any open wound over a bony
injury is an open fracture
75
Case Scenario #5
Goal: Reduce/eliminate further risk
of contamination
Do not manipulate extremity
– Do not want to inadvertently drag any
contaminate into wound
76
Case Scenario #6
Sprain or fracture???
Do you handle a sprain different from
a fracture?
– Orthopedic/musculoskeletal injuries are
handled the same
– Will need further
diagnostics for
definitive diagnosis
77
Case Scenario #6
Wounds change appearance after
hours to days
– Usually develop more swelling and
discoloration
Bruising from bleeding into surrounding tissue
– Blood will get reabsorb over time
– Color of bruise indicates general age of
injury
– Document color of bruise noted versus
using words “new” or “old”
78
Age of Bruise/Injury
0 - 2 days – red
2 – 5 days – blue and purple
5 - 7 days – green
7 – 10 days – yellow
10 – 14 days – brown
2 -4 weeks – no
further evidence
79
Case Scenario #7
Your patient was casted 2 days ago
for a fractured fibula/tibia
– You can see a cast on the lower
extremity
– Patient complains of pain “off the chart”
– They are agitated, miserable, and
demanding fro you to do something for
the pain
– Toes are swollen and discolored
– Capillary refill is present
80
Case Scenario #7
What is your impression?
– Patient may no have kept leg elevated
– Patient may not have filled prescription for
pain medication
– Patient has a low pain tolerance level
– Worse case scenario: patient has a
compartment syndrome
This is a true emergency
If not recognized and treated promptly, patient
may need amputation
Outstanding feature: pain out of proportion;
pain with passive stretching
81
Case Scenario #7
What can you do in the field for possible
compartment syndrome???
– Elevate extremity
To reduce swelling
– Apply ice packs to site
Can be effective even through a cast
– Evaluate distal CMS/PMS/SMV and document
At the hospital, after evaluation, patient
may receive a fasciotomy to relieve
intense elevated pressures within the
muscle compartment
82
Case Scenario #7
Fasciotomy left open until pressures
go down
Patient eventually returns to surgery
to have wounds closed
83
Bibliography
Bledsoe, B., Porter, R., Cherry, R.
Paramedic Care Principles &
Practices, 4th edition. Brady. 2013.
Region X SOP’s; IDPH Approved
January 6, 2012.
Mistovich, J., Karren, K. Prehospital
Emergency Care 9th Edition. Brady.
2010.
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