MASTER TEACHING NOTES
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Detailed Lesson Plan
Chapter 30
Musculoskeletal Trauma
120–130 minutes
Case Study Discussion
Teaching Tips
Discussion Questions
Class Activities
Media Links
Knowledge Application
Critical Thinking Discussion
Chapter 30 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
I.
5
10
Master Teaching Notes
Introduction
Case Study Discussion
A. During this lesson, students will learn to assess and treat a painful, swollen,
or deformed extremity.
B. Case Study
1. Present Dispatch and Upon Arrival information from the chapter.
2. Discuss with students how they would proceed.
II. Musculoskeletal System Review—The Muscles
A. Voluntary (skeletal) muscles are under control of a person’s will.
B. Voluntary muscles make possible all deliberate acts such as walking,
chewing, and frowning.
C. Most voluntary muscles are attached to the skeleton at one or both ends.
D. Voluntary muscles form the major muscle mass of the body.
E. Muscle tissue contracts when stimulated by a nerve impulse.
F. Muscles give our bodies their distinctive shapes.
G. Muscles can be injured in many ways.
1. Broken fibers from overextension
2. Bruises
3. Crushing
4. Cuts
5. Tears
6. Painful swelling and weakness
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 30

What are the patient management
priorities in such a situation?
 Describe how you will proceed with this
patient.
Teaching Tip
Since this section is review material, rely
more heavily on questioning students rather
than providing information.
Knowledge Application
Students should be able to use the
information in this section to assess and
describe musculoskeletal injuries.
Discussion Question
What happens to the shape of the muscles
when they contract?
PAGE 1
Chapter 30 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
5
5
10
Content Outline
Master Teaching Notes
III. Musculoskeletal System Review—Tendons and Ligaments
A. The “glue” that holds the body together
B. Composed of specialized connective tissue
1. Tendons connect muscle to bone.
2. Ligaments connect bone to bone.
C. Can be bruised, crushed, cut, or torn
IV. Musculoskeletal System Review—Cartilage
A. Extension of the bone
B. Comprised of connective tissue
C. Strong, smooth, flexible, compressible, slippery substance
D. Found at the point of articulation of two bones
E. Protects bones in motion from friction
F. Acts as shock absorber between bone surfaces
G. Leads to joint pain when injured
Discussion Question
V. Musculoskeletal System Review—The Skeletal System
A. Upper extremity (shoulder girdle, arm, forearm, hand)
1. Clavicle (collar bone)
2. Scapula (shoulder blade)
3. Humerus (upper arm bone)
4. Radius (lower arm bone)
5. Ulna (including the olecranon) (lower arm bone and elbow)
6. Carpal bones (wrist bones)
7. Metacarpals (hand bones)
8. Phalanges (finger bones)
B. Lower extremity (pelvis, thigh, leg, foot)
1. Pelvis (including the ilium, ischium, and pubis)
2. Femur (thigh bone)
3. Patella (kneecap)
4. Tibia (lower leg bone)
5. Fibula (lower leg bone)
6. Calcaneus (heel bone)
7. Tarsals (ankle bones)
8. Metatarsals (foot bones)
9. Phalanges (toe bones)
Discussion Questions
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 30
What is the function of cartilage?

What are the components of the
appendicular skeleton?
 Where is the greater trochanter of the
femur?
Class Activity
Assign groups of students to prepare
presentations to review the musculoskeletal
system. Divide the following topics among
the groups: Skeletal Muscle, Axial Skeleton,
Shoulder Girdle and Upper Extremities,
Pelvis and Lower Extremities, and Types of
Joint Movements. Give students 20 minutes
to prepare before reporting back to the
class.
PAGE 2
Chapter 30 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
15
Content Outline
Master Teaching Notes
VI. Injuries to Bones and Joints—Types of Injuries
A. Fracture
1. A break in the continuity of a bone
2. Caused by direct force, indirect force, or twisting force
3. Open fracture—Associated with an open wound
4. Closed fracture—Skin is not broken.
5. Type can only be distinguished by X-ray.
a. Hairline fracture—Small crack in bone, does not create instability
b. Pathologic fracture—Result of degenerative disease such as
osteoperosis
6. Can result in various complications
a. Hemorrhage from the bone
b. Instability of the extremity
c. Surrounding tissue damage
d. Infection (open fracture)
e. Interruption of distal blood supply
B. Strain
1. Injury to a muscle or tendon
2. Often due to overextension (overstretching)
3. Can be caused by extreme muscle stress or fatigue associated with
overuse
4. No edema or discoloration
5. Pain or weakness with use of the muscle
C. Sprain
1. Injury to a joint capsule
2. Damage to or tearing of the connective tissue
3. Usually involves ligaments
4. Usually occurs in shoulder, knee, or ankle
5. Immediate pain and tenderness, followed by inflammation and swelling
D. Dislocation
1. Displacement of bone from normal position in joint
2. Caused by joint being forced beyond normal range of motion
3. Obvious deformity and swelling; pain and tenderness
4. May occur at shoulder, elbow, wrist, hand, hip, knee, ankle, or foot
E. General injury considerations
1. Similar signs and symptoms: swelling, pain, or deformity
2. Usually associated with external forces (falls, vehicle collisions)
3. May occur through degenerative disease, particularly in elderly patients
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 30
Teaching Tip
Obtain and show a variety of radiographs of
orthopedic injuries.
Discussion Questions

Which joints are most commonly
dislocated?
 Why should you consider dislocations
significant injuries?
Knowledge Application
Students should be able to recognize a
painful, swollen, deformed extremity as well
as other indications of musculoskeletal
injury.
Weblinks
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access web resources
on osteoperosis, fractures (including
images), growth plate injuries, and
additional fracture information from the
Journal of the American Medical
Association.
Video Clip
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a video on joint
injuries.
PAGE 3
Chapter 30 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
4. Force may cause injuries to surrounding soft tissues and other body
areas
3
VII. Injuries to Bones and Joints—Mechanism of Injury
A. Direct force—Injury occurs at the point of impact.
B. Indirect force—Force impacts on one end of a limb, causing injury some
distance away from point of impact.
C. Twisting force—One part of extremity remains stationary while the rest
twists.
Discussion Questions

What is an example of direct force
applied to a bone?
 What is an example of indirect force
applied to a bone?
Weblink
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a web resource
on tennis elbow.
VIII. Injuries to Bones and Joints—Critical Fractures: The Femur and
5
the Pelvis
A. Femur
1. Symptoms
a. Bone itself bleeds heavily—Up to 1.5 liters of blood
b. Tension on thigh muscles is lost so thigh diameter increases,
allowing more blood to be housed within thigh.
2. Goals of treatment
a. Immobilize bone ends.
b. Reduce bleeding.
3. Effect of traction splint
a. Bone ends are realigned, preventing further injury and reducing
pain.
b. Diameter of thigh is decreased, allowing less blood to accumulate.
B. Pelvis
1. Bone itself bleeds heavily—Up to two liters of blood
2. Application of Pneumatic Antishock Garment (PASG) will stabilize
fracture and may help tamponade bleeding pelvis.
20
IX. Injuries to Bones and joints—Assessment-Based Approach: Bone
or Joint Injuries
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 30
Class Activity
Divide the class into small groups to
PAGE 4
Chapter 30 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
A. Scene size-up and primary assessment
1. Take appropriate Standard Precautions.
2. Consider the mechanism of injury.
3. Ask bystanders what caused the injury.
4. Try to imagine the forces to which the patient’s body was subjected.
5. Check for obvious signs of severe hemorrhage.
6. Look for signs of shock and treat.
7. If the injury has caused a life-threatening condition, immobilize injured
extremity and transport immediately following secondary assessment.
B. Secondary assessment
1. If the patient has a life-threatening condition not directly related to the
injury, initiate transport and immobilize injury en route if time and
patient’s condition permits.
2. If the patient is responsive and oriented, inspect and gently palpate bone
or joint.
3. Be gentle and reassuring.
4. Check injury site for signs and symptoms of injury (deformity,
contusions, tenderness, and so on).
5. Assess baseline vitals and obtain a history from the patient.
6. Evaluate the six “Ps.”
a. Pain
b. Pallor
c. Paralysis—May indicate nerve, muscle, tendon, or ligament damage
d. Paresthesia (numbness, prickly feeling, or tingling)—May indicate
nerve damage
e. Pressure—May indicate damaged tissue or internal blood loss
f. Pulse—Decrease to or absence of distal pulse may indicate arterial
damage.
C. Emergency medical care
1. If injury threatens patient’s life, immobilize injured extremity during
primary assessment or secondary assessment if the appropriate
resources are available and it does not cause a delay in transport.
2. If the patient has other life-threatening conditions, initiate transport and
immobilize injured extremity en route if time and patient’s condition
permits.
3. Immobilize the suspected fracture.
a. Use proper Standard Precautions.
b. Administer oxygen if needed.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 30
practice assessment of musculoskeletal
injuries.
Critical Thinking Discussion
How can you balance the need for
immediate transport of a patient in shock
with the need to immobilize major fractures
to prevent further bleeding, tissue damage,
and pain?
PAGE 5
Chapter 30 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
c. Maintain in-line spine stabilization if spine injury is suspected.
d. Splint bone and joint injuries.
e. Apply cold packs to painful, swollen, or deformed extremity.
f. Elevate the extremity (if spine injury is not suspected).
g. Transport.
D. Reassessment
1. Recheck patient’s vital signs and interventions.
2. Make certain injured extremity is properly immobilized.
3. Make sure immobilization has not adversely affected patient’s distal
pulses, motor function, or sensation.
X. Injuries to Bones and Joints—Summary: Assessment and Care
2
A. Review possible assessment findings and emergency care for
musculoskeletal injuries.
B. Review Figures 30-15 and 30-16.
XI. Basics of Splinting—General Rules of Splinting
5
A. Before and after applying the splint, assess pulse, motor function, and
sensation distal to the injury.
B. Immobilize joints above and below a long bone injury.
C. Remove or cut away clothing and jewelry around the injury site.
D. Cover all wounds with sterile dressings and gently bandage before splinting.
E. If there is severe deformity or the distal extremity is cyanotic (bluish) or lacks
pulses, align injured limb with gentle manual traction before splinting.
F. Never intentionally replace protruding bones or push them back below the
skin.
G. Pad each splint to prevent pressure and discomfort.
H. Apply the splint before trying to move the patient.
I. When in doubt, splint the injury.
J. If the patient shows signs of shock, do not apply a splint first; align him in the
normal anatomical position, treat for shock, and transport immediately.
XII. Basics of Splinting—Splinting Equipment
10
What are the general rules of splinting?
Knowledge Application
Given a series of scenarios, students
should be able to assess musculoskeletal
injuries, assign injuries proper priority in the
overall management of the patient, and
demonstrate proper splinting techniques.
Video Clip
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a video about
long bone injuries and splints.
Teaching Tips

A. Rigid splints
1. Commercially manufactured
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
Discussion Question
DETAILED LESSON PLAN 30
Show examples of each type of splint as
you talk about it.
PAGE 6
Chapter 30 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
B.
C.
D.
E.
F.
G.
H.
Master Teaching Notes
2. Made of wood, wood fiber, plastic, or cardboard
3. Designed to fit specific limbs, or can be molded to fit any appendage
4. May come with washable pads
Pressure (air or pneumatic) splints
1. Soft and pliable before inflation; rigid once applied and inflated
2. Cannot be sized
3. May impair circulation
4. May interfere with ability to assess pulses
5. May lose or gain pressure with changes in temperature/altitude
6. Seek medical direction regarding use
Traction splints
1. Provide a counterpull that alleviates pain, reduces blood loss, and
minimizes further injury
2. Purpose is to immobilize bone ends, reduce diameter of thigh, and
prevent further injury.
3. Many types available
Formable splints
1. Rigid but made to be shaped to fit deformed extremity
2. Can be fixed in place with cravats or Velcro
3. Typically comprised of wire, aluminum, or other flexible metal
Vacuum splints
1. Soft and pliable
2. Easily formed to deformed extremities
3. When air is sucked out, splint becomes extremely rigid.
Sling and swathe
1. Provides stability to injured shoulder, elbow, or upper humerus
2. Sling supports arm; swathe holds arm against chest.
3. Minimizes pain and further injury
Spine board
1. Considered a full body splint
2. Use in cases of critical injury to provide stability where extremity
fractures cannot be splinted at scene.
Improvised splints
1. Light in weight but firm and rigid
2. As wide as thickest part of fractured limb
3. Long enough to extend past joints and prevent movement
4. Padded well so inner surfaces are not in contact with skin
5. Possible materials include cane, cardboard, umbrella, pillow, and so on.
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 30

Provide students with adequate time to
practice splinting under supervision.
Discussion Question
What are some advantages and
disadvantages of rigid splints?
Video Clip
Go to www.bradybooks.com and click on
the mykit link for Prehospital Emergency
Care, 9th edition to access a video on the
application of a Sager splint.
Class Activity
Have a contest to see which group of
students can come up with the best
improvised splint.
PAGE 7
Chapter 30 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
XIII. Basics of Splinting—Hazards of Improper Splinting
5
A.
B.
C.
D.
E.
Compression of nerves, tissues, and blood vessels
Delay in patient’s transport
Reduction of distal circulation
Aggravation of bone or joint injury
Aggravation or cause of damage to tissue, nerves, blood vessels, or
muscles
XIV. Basics of Splinting—Splinting Long Bone Injuries
5
A. Look for exposed bone ends, joints locked in position, paresthesia (tingling),
paralysis, and pallor.
B. Assess the pulse and motor and sensory function below the injury site.
C. If limb is severely deformed, cyanotic (bluish), or lacks distal pulses, align
with gentle traction.
XV. Basics of Splinting—Splinting Joint Injuries
5
A. Look for paresthesia (tingling) or paralysis.
B. Assess the pulse and motor and sensory function below the injury site.
C. If distal extremity is cyanotic (bluish) or lacks distal pulses, align with gentle
traction; stop if pain or crepitus increases.
XVI. Basics of Splinting—Traction Splinting
3
A.
B.
C.
D.
XVII.
2
Discussion Question
Use for fractured femur.
Reduces diameter of thigh
Decreases space in which bleeding can occur
Do not use in the following instances.
1. Injury is within one to two inches of the knee or ankle.
2. Knee itself is injured.
3. Hip is injured.
4. Pelvis is injured.
5. There is partial amputation or avulsion with bone separation.
What is the mechanism by which traction
splinting works?
Basics of Splinting—Splinting Specific Injuries
A. Special techniques may be applied to the splinting of suspected bone and
joint injuries to specific sites.
B. Review splinting techniques for the shoulder, upper arm, elbow, forearm,
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
DETAILED LESSON PLAN 30
PAGE 8
Chapter 30 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
Master Teaching Notes
wrist, hand, fingers, pelvis, hip, thigh, knee, lower leg, ankle, and foot in
EMS Skills 30-07 and 30-08.
XVIII. Basics of Splinting—Pelvic Fracture
5
A. Pneumatic Antishock Garment (PASG) can splint pelvis and decrease
compartment size to reduce bleeding.
B. Commercial pelvic splint is another method.
C. Improvised pelvic wrap may be applied if necessary.
1. Fold a sheet lengthwise to eight-inch width.
2. Slide it under the small of the back, then down under the pelvis until
centered. Ends of the sheet must be of equal length on both sides of
patient.
3. Cross tail ends over patient and twist until sheet is tightly secured
around pelvis.
4. Tuck sheet ends under patient or tie into square knot.
5. Place patient on backboard or rigid device.
XIX.
5
Basics of Splinting—Compartment Syndrome
A. May occur when fracture or injury to an extremity has occurred
B. May occur in buttocks or abdomen
C. Occurs when pressure in space around capillaries exceeds pressure needed
to perfuse tissues; blood flow is cut off and cells become hypoxic.
D. Usually develops over time as edema around injured area increases
E. Commonly associated with fractures, bleeding from trauma, crush injuries,
and high-energy trauma
F. Signs and symptoms
1. Severe pain or burning sensation
2. Decreased strength in extremity
3. Paralysis of extremity
4. Pain with movement
5. Extremity feeling hard to palpitation
6. Distal pulses, motor, and sensory function possibly normal
G. Treatment
1. Immobilize and splint affected extremity.
2. Elevate extremity and apply cold pack or ice.
3. Transport the patient as soon as possible.
XX. Follow-Up
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
Discussion Question
What is compartment syndrome?
Critical Thinking Discussion
What causes the pain and paresthesia
associated with compartment syndrome?
Case Study Follow-Up Discussion
DETAILED LESSON PLAN 30
PAGE 9
Chapter 30 objectives can be found in an accompanying folder.
These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines.
Minutes
Content Outline
10
A. Answer student questions.
B. Case Study Follow-Up
1. Review the case study from the beginning of the chapter.
2. Remind students of some of the answers that were given to the
discussion questions.
3. Ask students if they would respond the same way after discussing the
chapter material. Follow up with questions to determine why students
would or would not change their answers.
C. Follow-Up Assignments
1. Review Chapter 30 Summary.
2. Complete Chapter 30 In Review questions.
3. Complete Chapter 30 Critical Thinking.
D. Assessments
1. Handouts
2. Chapter 30 quiz
PREHOSPITAL EMERGENCY CARE, 9TH EDITION
Master Teaching Notes
DETAILED LESSON PLAN 30
Do you agree with the choice of splints?
Why or why not?
Class Activity
Alternatively, assign each question to a
group of students and give them several
minutes to generate answers to present to
the rest of the class for discussion.
Teaching Tips

Answers to In Review and Critical
Thinking questions are in the appendix
to the Instructor’s Wraparound Edition.
Advise students to review the questions
again as they study the chapter.
 The Instructor’s Resource Package
contains handouts that assess student
learning and reinforce important
information in each chapter. This can be
found under mykit at
www.bradybooks.com.
PAGE 10