Assessing and Treating
Musculoskeletal Injuries
May 2012 CE
Condell Medical Center
EMS System
Site Code: 107200E -1212
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Rev 6/14/12
1
Objectives
Upon successful completion of this module, the EMS
provider will be able to:
• 1. Discuss components and function of the
muscular and skeletal systems.
• 2. Predict injuries based on the mechanism of injury.
• 3. Differentiate between fractures, dislocations, sprains,
and strains.
• 4. Describe the six P’s evaluated during a
musculoskeletal assessment.
• 5. Explain the general guidelines for splinting.
• 6. Describe signs and symptoms of compartment
syndrome.
2
Objectives cont’d
• 7. Describe complications of compartment syndrome.
• 8. Describe complications of crush syndrome.
• 9. Demonstrate proper measurement and placement
of a cervical collar.
• 10. Demonstrate proper application of the KED.
• 11. Demonstrate proper application of the HARE
traction (or similar traction based on your
department).
• 12. Demonstrate standing take down with the back
board.
• 13. Successfully complete the post quiz with a score of
80% or better.
3
Components - Musculoskeletal
System
• Composed of:
– Bones (dense connective tissue)
– Joints (place where bones meet)
– Muscles (tissues or fibers)
• Skeletal (voluntary), smooth (involuntary), cardiac
– Cartilage (connective tissue)
– Tendons (bands of connective tissue)
– Ligaments (connective tissue)
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Function - Musculoskeletal System
•
•
•
•
•
Provide the framework of the body
Support and protect internal organs
Allow movement of body parts or organs
Storage of salts and minerals
Production site of red blood cells
5
Bone Marrow
• Highly vascular
• Manufactures
important blood
components
6
Musculoskeletal Injuries
• Strain
– Muscle injury from overstretching or
overexertion of the muscle
• Spain
– Stretching or tearing of ligaments
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Musculoskeletal Injuries
• Dislocation
– Disruption of a joint
• Fracture
– Any break in a bone
– Simple = closed fracture
– Compound = open fracture
• Increased risk of contamination & infection
– Most common bone injury
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Cascade of Events
• Fracture occurs       
 Destruction of blood vessels in periosteum &
bone and damage to surrounding vessels
Swelling of soft tissue
Formation of a clot in the area
Cell death at injury site due to disruption of blood
flow
Intact surrounding cells divide & form a mass
around fracture site
New bone is generated in weeks or months
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Assessment Musculoskeletal
Injuries
• “5 P’s” of evaluation
Pain or tenderness?
Pallor – paleness or poor capillary refill?
Paresthesia – pins and needles sensation?
Pulses – diminished or absent?
Paralysis – inability to move?
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Signs & Symptoms
• Pain and tenderness
– Usually localized
• Deformity
– Compare for symmetry
• Grating or crepitus
– Increases pain levels
• Swelling
– From bleeding at the site
– Remove watches, rings as soon as possible
• Document what you did with the personal effects
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Signs & Symptoms cont’d
• Bruising- leaking of blood vessels
• Exposed bone ends
– Open/comminuted fracture
Increases risk of infection
Bone infection could lead to amputation
• Joints locked into place
– Often seen with dislocations
– Splint in position found
12
Signs & Symptoms cont’d
• Nerve & blood vessel compromise
– Evaluate distal CMS/SMV/PMS
• Evaluated before and after splinting
DOCUMENT CMS/SMV/PMS!!!
Document ALL assessment results
13
Assessment PEARL
• During assessment, determine mechanism
of injury
– If patient fell, ask “WHY”
• If fall related to tripping/losing balance, you
are just dealing with the orthopedic injuries
• If patient experienced dizziness,
lightheadedness, wooziness, syncope,
near-syncope…
–Consider a cardiac event until proven
otherwise
• Consider need for EKG monitoring
• Perform the Cincinnati Stroke Scale
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Care of the Injury
• Standard Precautions observed
• Perform baseline/initial assessment
PEARL
Musculoskeletal injuries are rarely ever life
threatening
 Could be life threatening for bilateral femur
fractures and pelvic fracture
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Care of the Injury cont’d
• Cover open wounds with sterile dressing
• If life threatening situation, splint enroute if
time
– Note: Patients on backboard are essentially
immobilized/splinted
• If stable patient, can splint prior to
transport
16
“RICE”
• R – rest the injury (i.e.: splinting)
• I – apply ice to wound
– Never apply ice directly to the skin
• Too damaging to the skin tissue and cells
• C – apply compression to minimize
swelling
– Never pull tight on the ACE – will be too
constrictive; let ACE unroll easily
• E – elevate higher than the heart
17
Guidelines for Splinting
• Must immobilize the joint above and joint
below the injury
– Minimizes movement which will decrease pain
– Prevents additional soft tissue injury to
nerves, arteries, veins, and muscle
– Prevents a closed fracture from becoming an
open fracture
– Minimizes blood loss
– Minimizes additional injuries to the site
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Deformity
• May make splinting difficult
• Chance of compromise to nerves, arteries,
and veins
• Distal tissue may die due to compromised
blood flow
• May need to add extra padding
• May need to be creative in choosing
splinting material
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When to Realign Deformed
Extremities
• Distal extremity cyanotic
• Distal pulses cannot be palpated
• When in doubt, call Medical control
• For relatively short transport times, most
injuries can and should be splinted in
position found
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Realigning an Injury
• Goal:
– Align joint to anatomical position
– Splints applied in position of anatomical
function
• Position mimics a normal, relaxed pose for
the extremity
–Fingers slightly curved for hands
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Realigning an Injury
• General guidelines to follow if necessary:
– 1 person grasps the distal extremity
– 1 person places hands above & below injury
– Apply gentle manual traction in the same
direction as the long axis of the extremity
• Stop if resistance is felt or bone ends may break
thru the skin
– Maintain gentle traction until splinting is
accomplished
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Splinting PEARLS
• Can’t treat what you can’t see
– Expose all injuries
• Assess and document distal
CMS/SMV/PMS before and after splinting
• Consider need for padding around bony
areas
• If bone is protruding, do not push it back in
– Cover with sterile gauze
23
Hazards of Splinting
Caring for extremity injuries prior to caring
for life threatening injuries
Inappropriately staying on the scene to
care for injured extremities prior to
initiating transport
Improper or inadequate splinting
– Too tight –circulation compromised
– Too loose –movement allowed further injury
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Potentially Fatal Orthopedic Injuries
• Bilateral femur fracture
– Typically results from excessive force
• Consider the presence of additional injuries
– Blood loss most likely with mid-shaft fractures
• Can lose up to 2 units of blood (1000 ml)
per femur fracture
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Stages of Shock
• Based on amount of blood loss
– Stage 1 – up to 15% circulation volume
• Average 500 – 750* ml (typical donation during
blood drive)
– Stage 2 – up to 15-25% circulation volume
• Average 750 – 1250* ml
– Stage 3 – up to 25-35% circulation volume
• Average 1250 – 1750* ml
– Stage 4 – up to >35% circulation volume
*Averages calculated for a 70 kg person
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Femur Fracture
• Presentation
– Extreme pain
• A lot of muscle tissue surrounding the femur
– Deformity
– Swelling
• Treatment
– Traction splint
• Best for mid shaft fractures
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Traction Splinting
• Relieves muscle spasm therefore reducing
pain
• Avoid if serious knee, tibial, or foot injuries
• Avoid if any joint injury to hip or knee is
suspected
– Anterior hip fracture may look like a femur
fracture
• Head of femur often protrudes in inguinal area
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Potentially Fatal Injury
• Pelvic fracture
– Frequently associated with extremity fractures
– Usually result from MVC and falls from heights
• Have high index of suspicion based on
mechanism of injury
– Can suffer from significant blood loss
• Bones have rich supply of blood
• Typically venous bleeding from disruption of
bone surface
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Pelvic Fractures
• The most significant pelvic injury is openbook pelvic fracture
– Symphysis is torn apart
– Anterior pelvis opened
like a book
– Both sacroiliac joints
usually disrupted
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Pelvic Fracture
• Assessment
– Instability or pain when applying gentle
posterior pressure on iliac crests or
symphysis pubis during assessment
• DO NOT ROCK PELVIS!!!
–Could displace the fracture or disturb a
hematoma
– Up to 40% of patients also have abdominal
injuries
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Compartment Syndrome
• Fascia is a non-stretching tough
membrane that surrounds muscles and
other structures in extremities
• Multiple closed spaces created called
compartments
• Bleeding and swelling from trauma may
create increased tissue pressure in the
confined space
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Compartments of the Leg
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Compartment Syndrome cont’d
• Increased pressure in confined space
– Decreased blood flow
– Hypoxia
– Possible muscle, nerve, vessel impairment
– May lead to cell death and amputation
• Typically presents hours after initial insult
• Surgical intervention required to relieve
the pressures in compartment
34
Compartment Syndrome
• Can occur with a patient with a casted
extremity
– Injured area continues to swell first few days
– Casted area constricted and does not allow
expansion of the swelling
– Compartments become compromised
– Have high index of suspicion for patient
presenting with a cast
• Pain level higher than expected usually the
tip off
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Signs and Symptoms Compartment
Syndrome
• Early
– Pain out of proportion to injury
– Paresthesia – pins & needles sensation
• Late – 5 P’s
– Pain
– Pallor
– Pulselessness
– Paresthesia
– Paralysis
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Compartment Syndrome
• Surgical intervention – fasciotomy
• Will need to return to OR for closure at a
later date
37
Compartment Syndrome
• Risks of late diagnosis and intervention
– Gangrene leading to need for amputation
– Ischemic contractures and therefore loss of
function
– Rhabdomyolysis and acute renal failure
• Syndrome caused by skeletal muscle injury
• Leakage of large quantities of toxic intracellular
contents into plasma
• Basically, sludge of muscle protein attempting to be
filtered thru kidneys is causing kidney damage
38
Crush Syndrome
• Pressure on extremities during prolonged
entrapment can disrupt blood flow
– Typically 4 hours or longer of entrapment
– Anaerobic metabolism in tissues occurs
– Toxins produced & released from crushed tissues,
muscles, and cells
•
•
•
•
•
Myoglobin - a muscle protein
Potassium
Phosphorus
Lactic acid – from anaerobic metabolism
Uric acid – from protein breakdown
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Crush Syndrome cont’d
• Patient at risk of cardiac dysrhythmia and
severe kidney damage from toxins
– Place patient on cardiac monitor
• Watch for peaked T wave
–Indication of excess potassium in
vascular space
– Increase IV fluid rate to keep kidneys
hydrated and flushed
40
Hyperkalemia – High Potassium
• Note peaked T wave (this is NOT ST elevation!!!)
• Excess extracellular potassium is an irritant to the
heart
– Watch for dysrhythmias and potential arrest
41
Types of Splints
•
•
•
•
•
•
•
Rigid material
Air splint
Vacuum splint
Slings
HARE/Sager traction splint
Back board
Pillows
42
Cervical Collar PEARLS
• Measure accurately for best fit
• Improper fit causes greater risk of harm
than it does good
• Measure bottom of chin to top of shoulder
• Eyes must be
focused straight
ahead
43
KED PEARLS
• Helpful only when rapid extrication is not
required
• Maintain manual spinal motion restriction
until fully secured
• Carefully place the
leg/thigh straps
especially in the male
population
44
HARE or Sager Traction PEARLS
• Traction maintained manually until device
in place and foot traction applied
• Patients often experience instant relief of
pain (from muscle spasms) once traction
in place
45
Standing Backboard
• Takes 3 persons to be safely performed
• If you really need
spinal motion
restriction, doesn't
make sense to have
patient walk to cot
and then lay down
46
Standing Backboard
PEARL
• Apply straps to finish securing the patient
AFTER the patient is supine on the board
• The patient will be manually held in place
while the backboard is being lowered
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Documentation
• Assessment of injury by interview
– Onset – what were you doing at the time?
– Provocation/palliation – what makes the pain
worse/better?
– Quality – in your words, describe the pain
– Radiation – does the pain radiate?
– Severity – on a scale of 0-10, rate your pain
– Time – what time did this happen?
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Documentation cont’d
• Observation of appearance
– Blood loss present?
– Deformity present?
– Bruising present?
• Assessment by palpation (CMS/SMV/PMS)
– Pulses
• Distal compared to proximal
– Ability to wiggle distal extremities
– Ability to differentiate area touched
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Documentation cont’d
– Consider the 6 P’s of extremity assessment
Pain
Pallor
Paralysis
Paresthesia
Pressure
Pulses
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Case Scenario Discussion
• Review the following cases
• Follow the printed questions to prompt
discussion
• Consider creative alternative to care for
the wound when presented with unique
challenges
– There are not necessarily only one right
answer for each question posed
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Case Scenario #1
• EMS called to a road construction crew
• Patient’s arm caught under a road
compacting machine for a few minutes
• What safety issues need to be
considered?
– Traffic
– Securing machine from movement
– Exposure to blood and body fluids
52
Case Scenario #1
• How would you assess this wound?
• How would you care for this wound?
• How would you document this wound?
53
Case Scenario #1
• Assess distal circulation, motion, and
sensation status
• Can rinse gross debris away
– Always use sterile normal saline on open wounds
• Avoid using sterile water on open wounds
• Normal saline is isotonic; less destructive to damaged
tissue
• Cover open wound
• Splint extremity in position of function
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Case Scenario #1
• Documentation
– Mechanism of injury (MOI)
– Appearance of wound
– Distal CMS/SMV/PMS before and after
splinting
– Type of splinting/immobilization performed
– Pain control measures
– Response to interventions
55
Case Scenario #2
• EMS received a call to a local factory for a
patient with their arm caught in machinery
• Upon arrival, you note the right forearm is
caught in a machine
• What safety issues need to be
considered?
56
Case Scenario #2
• How would you assess this wound?
• How would you care for this wound?
• How would you document this wound?
57
Case Scenario #2
• What risks to the patient are associated
with crush injuries?
– Release of toxins into the bloodstream once
the pressure is released especially after long
entrapment
– Circulating potassium is a cardiac irritant
• Watch for dysrhythmias via cardiac monitor
– By-products of myoglobinemia can decrease
kidney function causing acute renal failure
• Provide IV fluids
58
Case Scenario #3
• EMS responded to the scene for a patient
injured during a fall
• Upon arrival, you note an elderly female
sitting on the ground supporting their left
arm
59
Case Scenario #3
• How would you assess this wound?
• Distal CMS/SMV/PMS before and after
splinting
• How would you care for this wound?
– Splint in position found
– May need to pad splint material
– Apply ice over splinting material
– Elevate arm
60
Case Scenario #3
• What else do you need to think about in
caring for this patient?
– WHY DID THE PATIENT FALL???
• Remember: Unless it is a clumsy tripping, consider
a cardiac/stroke issue until proven otherwise
– Obtain EKG rhythm strip
– Perform Cincinnati Stroke Scale
61
Case Scenario #3
• What do you think about this documentation?
– Upon arrival found patient sitting on the ground
supporting arm
– Site evaluated
– Pain 9/10; 7/10
– Above vital signs obtained
– Patient placed on backboard and in collar
– Patient transported
62
Case Scenario #3
• Documentation issues
Why did patient fall?
What did you find on assessment of the injury?
How did you splint the injury?
What was the distal CMS/SMV/PMS before and
after splinting?
What were the responses to interventions
applied?
63
Case Scenario #3
• Drug/solution area filled in:
– O2 4l per nasal cannula
• What about pain control?
– Patient could get Fentanyl
• Why is oxygen applied?
– Remember criteria: SpO2 <94% and/or
respiratory complaints or compromise
64
Case Scenario #4
• EMS called for a 5 y/o pedestrian who fell
exiting a bus and then was run over
• The scene is chaos
– Congested with parents, neighbors, bus driver,
other children still on the bus
65
Case Scenario #4
For discussion
• What safety issues need to be considered?
• How do you exert crowd control?
• Describe patient assessment
– What additional injuries may have occurred?
– What trauma category is this patient?
• Describe treatment of wounds
66
Case Scenario #4
• Injury contained to left leg
– Bone deep laceration to left patella
– Quadricep tendon cut through
– Skin over anterior left leg avulsed – bone
exposed
– Tendons in ankle exposed
– Tendons over dorsum foot severed from
proximal insertion
– Metatarsals exposed
67
Case Scenario #4
• How would you assess this wound?
• After viewing the OR picture of the wound,
discuss how you would assess status of distal
circulation
• How would you care for this wound?
• How would you document this wound?
68
Case Scenario #4 Hospital Course
• Hypotensive and unstable on admission
– Amputation was anticipated
• Debridement performed 5 days post injury
• 13 days post injury external fixator applied;
removed in 15 days and replaced for another 7
days
• 25 days post injury skin grafting done
• Multiple surgeries for removal fixator, casting,
cast removal
• Outcome: limb shortened, foot drop present but
functional
69
Case Scenario #4 OR Repair
• Fixator pins
noted
• Donor site for
skin grafting
• Mesh skin
graft in place
70
Case Scenario #5
• Crush injury to hand
• What safety issues need to be considered
at the site?
– Is scene
safe?
– Are BSI’s
in place?
71
Case Scenario #5
• How would you assess this wound?
• How would you care for this wound?
• Anything special in the care based on the
picture?
– Any constricting material (ie: the ring) need to
be removed ASAP
• Document what you did with personal
effects taken from the patient
• How would you describe this wound?
72
Equipment Practice
• Form small groups
• Practice proper utilization of
– Measurement and placement of cervical collar
– Application of KED
– Application of back board with “patient”
standing
73
Bibliography
• Region X Advanced Life Support Standard Operating
Procedures February 1, 2012
• Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles & Practices Third Edition. Brady. 2009.
• Campbell, J. International Trauma Life Support for
Emergency Care Providers. 7th edition. Pearson. 2012.
• Limmer, D., O’Keefe, M. Emergency Care 12th Edition.
Brady. 2012.
• emedicine.medscape/article/1007814-overview
• lifeinthefastlane.com
• modernmedicine.com
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