Chapter 37
Orthopaedic Trauma
National EMS Education
Standard Competencies
Trauma
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression to implement a
comprehensive treatment/disposition plan for
an acutely injured patient.
National EMS Education
Standard Competencies
Orthopaedic Trauma
• Recognition and management of
− Open fractures
− Closed fractures
− Dislocations
− Amputations
National EMS Education
Standard Competencies
• Pathophysiology, assessment, and
management of
− Upper and lower extremity orthopaedic trauma
− Open fractures
− Closed fractures
− Dislocations
− Sprains/strains
National EMS Education
Standard Competencies
• Pathophysiology, assessment, and
management of (cont’d)
− Pelvic fractures
− Amputations/replantation
− Compartment syndrome
− Pediatric fractures
− Tendon laceration/transection/rupture
National EMS Education
Standard Competencies
Medicine
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression and implement a
comprehensive treatment/disposition plan for
a patient with a medical complaint.
National EMS Education
Standard Competencies
Nontraumatic Musculoskeletal
Disorders
• Anatomy, physiology, assessment, and
management of
− Nontraumatic fractures
National EMS Education
Standard Competencies
• Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management
of common or major nontraumatic
musculoskeletal disorders
− Disorders of the spine
− Joint abnormalities
− Muscle abnormalities
− Overuse syndromes
Introduction
• Musculoskeletal injuries are one of the most
common reasons for seeking medical
attention.
− Easily identified by pain, swelling, and deformity
− May cause short- or long-term disability
− Always check for life-threatening injuries first.
Functions of the
Musculoskeletal System
• Supports the soft tissues of the body
• Generates movement
• Protects fragile organs and structures
• Generates blood cells (hematopoiesis)
The Body’s Scaffolding: The
Skeleton
• Axial skeleton
−
−
−
−
Vertebral column
Skull
Rib cage
Spinal column
• Appendicular skeleton
− Pectoral girdle
− Pelvic girdle
− Upper and lower
extremities
Shoulder and Upper
Extremities
• The pectoral girdle is composed of:
− Two scapulae (shoulder blades)
− Two clavicles (collarbone)
Shoulder and Upper
Extremities
• The upper
extremity joins the
shoulder girdle at
the glenohumeral
joint.
• The forearm is
made up of the
radius and ulna.
Shoulder and Upper
Extremities
• Hand consists of:
− Carpals
− Metacarpals
− Phalanges
Pelvis and Lower Extremities
• The pelvic girdle is
three bones fused
together:
− Ischium
− Ilium
− Pubis
Pelvis and Lower Extremities
• The lower
extremity is the:
− Thigh
− Leg
− Foot
Pelvis and Lower Extremities
• Three classes of
foot bones:
− Tarsals
− Metatarsals
− Phalanges
Characteristics and
Composition of Bone
• Bone shapes
− Long bones: longer than they are wide
− Short bones: nearly as wide as they are long
− Flat bones: thin and broad
− Irregular bones: shape serves a certain function
− Round bones: found in proximity to a joint
Characteristics and
Composition of Bone
• Typical long bone architecture
− Three regions:
• Diaphysis
• Epiphysis
• Metaphysis
− Articular surfaces join other bones, forming
joints.
Characteristics and
Composition of Bone
• Age-associated
changes in bone
− Bones decrease in
density, leading to:
• Loss of height
• Changes in facial
structure
− Osteoporosis is a
significant density
decrease.
Courtesy of Tim Arnett/University College London
Joints
• Formed when two bones come together
− Some are fused and allow for no motion.
− Others allow for motion by permitting movement
between the two bones.
Joints
Joints
• Types of joints
− Fibrous
− Cartilaginous
− Synovial
Joints
• Bursa: Padlike sac or cavity in the
connective tissue
− Contains fluid that helps reduce friction between
tendons and bones, or tendons and ligaments
− Bursitis: Inflammation of a bursa
Skeletal Connecting and
Supporting Structures
• Tendons connect muscle to bone.
• Ligaments connect bone to bone.
• Cartilage forms the smooth surface over
bone ends where they articulate.
The Moving Forces: Muscles
• Three types of
muscle:
− Cardiac
− Skeletal
− Smooth
The Moving Forces: Muscles
• Skeletal muscle
− Also known as voluntary or striated muscle
− Includes all muscles attached to the skeleton
− Affected by work to which they are subjected
− Attached to bones by tendons
The Moving Forces: Muscles
Muscle Innervation
• Occurs when somatic motor neurons
transmit electrical stimuli
− Motor units respond by either contracting or not.
Musculoskeletal Blood Supply
• Upper extremity’s supply comes from the
subclavian artery.
• Lower extremity’s supply comes from the
external iliac artery.
Musculoskeletal Blood Supply
Patterns and Mechanisms of
Musculoskeletal Injury
• A pathologic
fracture is
produced by a
force that generally
would not cause
harm to a healthy
bone.
Injury Forces and Motions
• Direct force
− Occurs when the force
of an impact is too
great to be absorbed
by the soft tissue
• Indirect force
− Occurs when the force
applied to one part of
the body is transmitted
to a weaker area
Fractures
• A break in the continuity of a bone
• Occur when the amount of force applied to
a bone overcomes the strength of the bone
Fractures
• Classification
− Based on:
• Direction of the
fracture line
• Number of
fractures
• Number of cortices
involved
Fractures
• Classification
− May be classified
based on type of
displacement
Fractures
• Classification
(cont’d)
− Open fracture: skin
is broken.
− Closed fracture:
skin remains intact.
Courtesy of Rhonda Beck
Fractures
• Signs/symptoms
− Pain close to site
− Deformity
− Shortening
−
−
−
−
Swelling
Guarding
Tenderness
Crepitus
− Exposed bone
© Chuck Stewart, MD.
Ligament Injuries and
Dislocations
• Dislocation: Bone is totally displaced from
the joint.
− Evaluation reveals:
• Obvious and significant deformity
• Significant decrease in joint’s ROM
• Severe pain
Ligament Injuries and
Dislocations
• Dislocation (cont’d)
− Subluxation: Partial dislocation
− Luxation: Complete dislocation
− Diastasis: Ligaments that hold two bones in
place are disrupted
Ligament Injuries and
Dislocations
• Sprains: Ligaments are stretched or torn.
− Typical symptoms include:
• Pain
• Swelling
• Discoloration over the injured joint
Muscle and Tendon Injuries
• Strains
• Achilles tendon rupture
• Injuries related to inflammatory responses
− Bursitis
− Tendinitis
Injuries That May Signify
Fractures
• Amputation:
Separation of a
limb or other body
part from the rest
of the body
− May be complete
or incomplete
Courtesy of Andrew N. Pollak, MD, FAAOS
Injuries That May Signify
Fractures
• Laceration: Smooth or jagged cut caused by
a sharp object or a blunt force
− Depth of the injury can vary.
− Deep lacerations may cause nerve injury.
Patient Assessment
• Patients may be classified based on injury:
− Life- or limb-threatening injury or condition
− Life-threatening injuries, simple musculoskeletal
trauma
− Life- or limb-threatening musculoskeletal trauma
− Isolated, non–life- or non–limb-threatening
injury
Scene Size-Up
• Focus on safety and standard precautions.
• Consider the mechanism of injury (MOI).
• Request additional resources as needed.
Primary Assessment
• Focus on mental status, ABCs, and priority.
• Priorities should include:
− Identifying the injuries
− Preventing further harm or damage
− Supporting the injured area
− Administering pain medication if necessary
Primary Assessment
• Form a general impression.
− Evaluate level of consciousness.
− If there was significant trauma, musculoskeletal
injuries may be a lower priority.
• Do not waste time on prolonged assessment.
• Complete additional assessment during transport.
Primary Assessment
• Airway and breathing
− Very little else matters if the patient’s airway
and breathing are inadequate.
− Evaluate the chief complaint and MOI.
Primary Assessment
• Circulation
− Hypoperfusion is a primary concern.
• Treat the patient for shock immediately.
• Assess for pulses proximal to injury, and note any
circulatory changes.
− Check for external bleeding.
Primary Assessment
• Transport decision
− Rapid transport should be provided for:
• Patients with airway or breathing problems
• Patients with significant bleeding
• Patients with a significant MOI
− Patients with simple MOIs may be stabilized
prior to transport.
History Taking
• Use the standard SAMPLE format.
• Obtain information about the incident.
− Condition and position of patient before incident
− Details of incident
− Position of patient after incident
Secondary Assessment
• Obtain a baseline set of vital signs.
• Compare one side of the injured extremity
with the other.
• Perform and exam, noting DCAP-BTLS.
Secondary Assessment
• Cover the 6 Ps:
−
−
−
−
−
−
Pain
Paralysis
Paresthesias
Pulselessness
Pallor
Pressure
• Pain
− Remember OPQRST
mnemonic.
− Ask the patient to rate
pain on a 1 to 10
scale.
Secondary Assessment
• Inspection
− Check for:
• Deformity
• Skin changes
• Swelling
• Muscle spasms
• Abnormal limb positioning
• Increased or decreased ROM
• Color changes
• Bleeding
Secondary Assessment
• Palpation
− Check for point tenderness.
− Identify instability, deformity, abnormal joint or
bone continuity, and displaced bones.
− Feel for crepitus.
− Palpate distal pulses.
• Palpate pelvis and upper and lower extremities.
Secondary Assessment
• Motor function and sensory exam
− Check that the patient does not have a lifethreatening injury.
− Consider the preinjury level of function.
− Compare both sides of the body.
Reassessment
• The overall goal is to identify the type and
extent of the injury and to provide treatment.
− Treatment begins in the field.
General Treatment of Fractures
and Sprains
• Fractures
− Control external
bleeding.
− Prevent infection.
− Manage internal
bleeding.
− Immobilize.
• Sprains
−
−
−
−
−
Immobilize.
Chill.
Elevate.
Splint.
Reduce weight
bearing.
− Manage pain.
Volume Deficit Due to
Musculoskeletal Injuries
• Prevent
hypotension and
instability.
− Apply pressure.
− Splint.
− Administer IV
fluids.
Pain Control
• Assess the patient’s pain level.
• Try simple measures to control pain.
− Splint
− Rest and elevation
− Heat or ice
• If measures fail, administer an analgesic or
antispasmodic agent.
Cold and Heat Application
• During the first 48 hours, cold packs can be
used to reduce pain and swelling.
• Heat therapy should be avoided in the first
48 to 72 hours, but can then be used to:
− Increase blood flow.
− Decrease stiffness.
Splinting
• Decreases pain
• Reduces risk of
further damage
• Controls bleeding
Principles of Splinting
• Make sure the injured area can be seen.
• Assess and record distal PMS functions.
• Cover all wounds with a sterile dressing.
• Do not move the patient before splinting.
• Fractures—immobilize bone ends and
joints.
Principles of Splinting
• Dislocations—splint entire length of bone.
• Pad the splint well.
• Support the injury and minimize movement.
• Splint knees straight, elbows at right angle.
• Discontinue traction if patient reports pain.
Principles of Splinting
• Splint firmly.
• Avoid covering fingers and toes.
• Apply cold packs, and elevate the limb.
• In the case of life-threatening injuries,
splinting should not delay transport.
Types of Splints
• Rigid splint
− Inflexible device
attached to a limb
− Must be padded
and long enough
− Use two providers
to apply.
Types of Splints
• Sling and swathe
− Slings are useful to
stabilize upper
extremities.
− Swathes add more
stabilization for:
• Injuries to clavicle
• Anterior
dislocations of the
shoulder
Types of Splints
• Pneumatic splints
− Stabilize fractures
to the lower leg or
forearm
− Advantages:
• Slow bleeding
• Minimize swelling
Types of Splints
• Pneumatic antishock garment (PASG)
− Used for injuries to lower extremities or pelvis.
− Be sure to check with medical control.
− Document injuries before applying.
− Do not remove in the field.
Types of Splints
• Vacuum splints
− Sealed mattresses
filled with air and
plastic beads
− Becomes rigid like
a plaster cast
Types of Splints
• Pillow splints
− Used to stabilize an injured foot or ankle
− Mold the pillow around the injury and secure in
place with cravats.
Types of Splints
• Traction splints
− Used to stabilize
femur fractures
− Reassess PMS
functions after
applying.
Types of Splints
• Buddy splinting
− Used for injuries to the fingers and toes
− An adjacent finger or toe acts as a splint.
− Avoid taping over joints or cutting off circulation.
Pediatric Fractures
• Weakness of growth plates makes
children’s bones vulnerable to fracture.
• Tenderness, swelling, and bruising tend to
be at a lower level.
• Pelvic fractures are unusual.
Assessment and Management
• When assessing, look for signs of abuse.
• Adjust your approach as needed.
• Stabilize all sprains and fractures.
• Transport child with a family member.
Complications of
Musculoskeletal Injuries
• Likelihood of complication is due to:
− Strength of force that caused the injury
− Location of the injury
− Patient’s overall health
Complications of
Musculoskeletal Injuries
• Paramedics can reduce the probability of
long-term disability by:
− Preventing further injury
− Reducing the risk of wound infection
− Minimizing pain
− Transporting to appropriate facility
Vascular and Neurovascular
Injuries
• Devascularization: Loss of blood flow to a
body part, occurring when blood vessels are
damaged following a musculoskeletal injury
• Neurovascular injuries occur when the
skeletal system is compromised.
Vascular and Neurovascular
Injuries
• Assessment and management
− Assess and reassess pulses.
− Control bleeding.
− Maintain adequate intravascular volume.
Compartment Syndrome
• Condition that occurs when pressure is too
high within fascia
• Causes include:
− Overly tight bandages, splints, casts, or PASG
− Fracture, dislocation, crush injury, vascular
injury, soft-tissue injury, bleeding disorder
− Fluid leakage or edema
Compartment Syndrome
• Assessment
− The first sign is searing or burning pain out of
proportion to the injury.
− Neurologic symptoms include:
• Paresthesias
• Paralysis of involved muscles
− Pulselessness is a late sign.
Compartment Syndrome
• Management
− Elevate the extremity to heart level.
− Apply cold packs.
− Open or loosen constrictive clothing or splint.
− Administer high-flow oxygen and isotonic
crystalloid solution.
Crush Syndrome
• Result of prolonged compressive force that
impairs muscle metabolism and circulation
− When force is released, contents of the muscles
enters the systemic vasculature, resulting in:
• Decreased blood pH
• Hyperkalemia
• Renal dysfunction
Crush Syndrome
• Assessment and management
− Before releasing the compressing force:
• Assess the ABCs.
• Administer supplemental oxygen and isotonic
crystalloid solution.
• Establish cardiac monitoring.
Crush Syndrome
• Assessment and management (cont’d)
− If ECG shows signs of hyperkalemia:
• Administer calcium to stabilize the myocardium.
• Administer sodium bicarbonate to promote the
intracellular shift of potassium.
Thromboembolic Disease
• Includes deep vein thrombosis (DVT) and
pulmonary embolism
• Signs and symptoms of DVT include:
− Disproportionate swelling of an extremity
− Discomfort in extremity that worsens with use
− Warmth and erythema of the extremity
Thromboembolic Disease
• Signs and
symptoms of
pulmonary
embolism include:
−
−
−
−
Sudden dyspnea
Pleuritic chest pain
Tachypnea
Right-side heart
failure
− Cardiac arrest
Thromboembolic Disease
• Signs and symptoms of fat embolism
include:
− Tachycardia
− Pulmonary congestion
− Petechiae
− Change in mental status
− Organ dysfunction
Thromboembolic Disease
• Treatment includes:
− Maintaining an airway
− Supplying adequate oxygen
− Maintaining intravascular volume
− Providing rapid transport
Shoulder Girdle
• The shoulder girdle consists of:
− Clavicle
− Shoulder
− Scapula
Shoulder Girdle
• Clavicle fractures:
− Pain in shoulder
− Swelling
− Unwillingness to raise
the arm
− Tilting of the head
toward fracture
• Shoulder injury:
− Swelling
− Ecchymosis
− Pain
• Scapular fracture:
− Pain that increases
with arm abduction
− Swelling
Shoulder Girdle
• Management
− Treat shoulder fractures with a sling or swathe.
− Treat suspected scapula fractures with full
spinal stabilization.
Midshaft Humerus Fractures
• Assessment
− Signs and symptoms include:
• Significant swelling
• Ecchymosis
• Gross instability of the region
• Crepitus
• Damage to upper arm nerves and blood vessels
Midshaft Humerus Fractures
• Management
− To correct angulated fractures, apply
longitudinal traction.
− Once the extremity is in place, apply a rigid
splint and a sling.
− Use cold packs to reduce pain and swelling.
Elbow
• Distal humerus
− Supracondylar
fractures typically
occur as a result of
falling onto an
outstretched hand.
• Proximal radius and
ulna
− Radial head fractures
occur as a result of
falling onto an
outstretched hand or
from a direct blow.
Elbow
• Signs of a distal
humerus fracture:
− Pain in the elbow
− Significant swelling
− Ecchymosis
• Signs of a radial head
fracture:
− Pain associated with
supination or
pronation
− Ecchymosis
Elbow
• Treatment of injuries is the same:
− Repeatedly assess for compartment syndrome.
− Conduct a neurovascular exam before splinting.
• If there is a distal pulse, splint.
• If there is no distal pulse, consult medical facility.
− Transport the patient gently.
Forearm
• Fractures may involve radius, ulna, or both.
• Typically occur as a result of:
− Direct blow (nightstick fracture)
− Falling onto outstretched hand (Colles fracture)
Forearm
• Signs of a Colles
fracture include:
− Dorsally angulated
deformity of the distal
forearm
− Pain
− Swelling
• Treatment includes:
− Splinting
− Application of cold
packs
− Neurovascular exams
Wrist and Hand
• Scaphoid
− Injuries result from
falling onto an
outstretched hand.
• Boxer’s fracture
− Occurs after punching
a hard object
• Metacarpal shaft
− Fractures result from a
crush injury or direct
trauma.
• Mallet finger
− Occurs when a finger
is jammed into an
object
Wrist and Hand
• Signs of scaphoid
fracture include:
− Pain
− Tenderness in the
anatomic snuffbox
• Signs of a boxer’s
fracture include:
− Pain over ulnar
aspect of the hand
− Swelling
Wrist and Hand
• Signs of metacarpal
fractures include:
− Abnormal rotation of
fingers
− Swelling of palm
− Pain
− Tenderness
• Signs of mallet finger
include:
− Inability to extend
distal phalanx
− Flexed position is
maintained.
Wrist and Hand
• Management
− Secure extremity to
an armboard or
rigid splint.
− Elevate the
extremity.
Courtesy of AAOS
Pelvis
• Disruptions of the
pelvic ring occur
secondary to highenergy trauma.
• If pelvic injury
exists, suspect
multisystem
trauma.
Pelvis
• Structures at risk for
injury with pelvis
fracture:
−
−
−
−
−
Bladder
Urethra
Rectum
Vagina
Sacral nerve plexus
• Blood vessels most
prone to damage:
− Veins within pelvis
• Nerves at greatest
risk of injury:
− Those in lumbar and
sacral regions
− Sciatic nerves
− Femoral nerves
Pelvis
• Lateral
compression pelvic
ring disruptions
− Result from side
body impact
Courtesy of Andrew N. Pollak, MD, FAAOS
− Lower risk of
hemorrhage
Pelvis
• Anterior-posterior compression pelvic ring
disruptions
− Occur following a head-on collision or fall
− Risk of hemorrhage is high.
Pelvis
• Vertical shear
− Occurs when a major
force is applied to
pelvis
− Results in increased
pelvic volume
• Straddle fracture
− Occurs after a fall
when a person lands
in the region of the
perineum
− Carries a risk of
complications
Pelvis
• Open pelvic fractures
− Injury to the major vascular structures can
cause life-threatening hemorrhage.
− May result from penetrating or blunt trauma
− Causes massive hemorrhage
Pelvis
• Signs of a stable
injury include:
− Pain in the pelvis
− Difficulty bearing
weight
• Signs of profound
injury include:
−
−
−
−
Shock
Gross instability
Diffuse pain
Possible bruising or
lacerations
− Possible hematuria
Pelvis
• Signs of a vertical
shear include:
− Significant shortening
of limb
− Possible massive
hemorrhaging into the
pelvis
• Signs of an open
fracture include:
− Blood in the vaginal or
rectal regions
Pelvis
• Assess mental status and ABCs.
• Assess the pelvis for bleeding, lacerations,
bruising, and instability.
• A search for entry and exit wounds should
not delay transport.
Pelvis
• Treatment should
include:
− Monitoring ABCs
− Spinal stabilization
− IV access
• The goal of
management is to:
− Reduce bleeding.
− Decrease instability.
• May include pelvic
binder
Pelvis
• To apply a pelvic
binder:
− Place binder over
the trochanters and
below the ribs.
− Connect sides.
− Apply pressure
from either side.
− Perform definitive
tightening.
EMS facility courtesy of St. Charles County Ambulance District, Missouri, ©
Ray Kemp/911 Imaging
Hip
• Fractures of the femoral head are usually
associated with a hip dislocation.
• Femoral neck and intertrochanteric
fractures are a result of falls.
• Proximal femoral shaft injuries result from a
high-energy mechanism.
Hip
• Signs and symptoms may include:
− Pain in the affected hip
− Inability to bear weight
− Reports of snapping sounds or feelings
− Externally rotated and shortened leg
− Tenderness to palpation
− Swelling, deformity, ecchymosis
Hip
• Treatment
depends on the
MOI.
− For older patients
with a low-energy
injury, support the
injured extremity
with pillows and
blankets.
Hip
• For younger patients with high-energy
injuries:
− Immobilize.
− Establish vascular access.
− Monitor for shock.
− Transport to a trauma center.
Femoral Shaft
• Fractures occur following high-energy
impacts.
• Signs and symptoms may include:
−
−
−
−
−
Angulation
Limb shortening
Thigh edema
Crepitus
Neurovascular damage
Femoral Shaft
• Treatment includes:
− Monitoring for shock
− Full spinal immobilization
− Establishing vascular access
− Use of a traction splint or PASG
− Administration of pain medication
Knee
• Fractures result from direct blows, axial load
of the leg, or contractions of quadriceps.
• Signs and symptoms include:
− Significant pain
− Decreased ROM
− Ecchymosis, swelling, deformity
Knee
• Management depends on status of pulses
− Good distal pulse—splint extremity in position
found.
− No pulse—seek medical consultation.
• Elevate the leg and apply cold packs.
• Perform frequent neurovascular checks.
Tibia and Fibula
• Fractures may result from direct trauma or
rotational or compressive forces.
• Signs and symptoms may include:
− Significant deformity
− Soft-tissue injury
Tibia and Fibula
• Treatment:
− Apply a rigid splint.
− Administer pain medication.
− In case of angulation, attempt to align the leg.
− Elevate the extremity to heart level.
− Apply cold packs.
Ankle
• Fractures usually result from sudden,
forceful movements of the foot.
Courtesy of Andrew N. Pollak, MD, FAAOS
Courtesy of Andrew N. Pollak, MD, FAAOS
Ankle
• Signs of an ankle
fracture include:
− Pain
− Deformity, swelling
− Damage to nerve and
blood vessels
− Compartment
syndrome
− Chronic pain and
arthritis
• Treatment includes:
− Stabilization
− Elevating extremity to
heart level
− Applying cold packs
− Reduction if
associated with a
pulseless foot
Calcaneus
• Fractures can occur when a patient jumps
and lands on the feet or a powerful force is
applied to the heel.
• Signs and symptoms may include:
− Foot pain
− Swelling
− Ecchymosis
Calcaneus
• Treatment includes:
− Splinting the extremity with a pillow
− Application of ice packs
− Spinal stabilization
Shoulder Girdle Injuries and
Dislocations
• Acromioclavicular
(AC) joint
separation
− Usually results
from a direct blow
to the superior
aspect of the
shoulder
Courtesy of Anand M. Murthi, MD
Shoulder Girdle Injuries and
Dislocations
• Posterior
sternoclavicular joint
dislocation
− Usually results from a
direct blow to the
clavicle
• Shoulder dislocation
− Usually results from a
fall onto an
outstretched arm
Shoulder Girdle Injuries and
Dislocations
• Signs of AC joint separation include:
− Pain
− Tenderness
− Possible protrusion of the distal clavicle
Shoulder Girdle Injuries and
Dislocations
• Signs of shoulder
dislocation include:
− Severe pain
− Decreased ROM
− Possible bulge at
the acromion
− Palpable humeral
head
− Muscle spasms
Courtesy of AAOS
Shoulder Girdle Injuries and
Dislocations
• Treat AC separation with a sling and
swathe.
• Treat posterior sternoclavicular dislocations
by positioning supine with arm abducted.
• Treat dislocated shoulders by splinting the
extremity in the position it was found.
Elbow Dislocation
• High risk of neurovascular injury
• Usually results from a fall onto an
outstretched hand or from hyperextension
of the elbow joint
− Nursemaid’s elbow is caused by a sudden pull
on a child’s arm.
Elbow Dislocation
• Signs of elbow
dislocation include:
− Pain, swelling,
ecchymosis
− Palpable deformity
− Locking or
resistance to
movement of joint
Elbow Dislocation
• Signs of radial head subluxation include:
− Injured arm held in flexion
− Refusal to move hand or elbow
− Mild swelling
• Treat dislocations and subluxations with a
splint.
Wrist and Hand Dislocation
• Occurs when wrist is hyperextended
• Signs and symptoms include:
− Pain
− Swelling
− Deformity
Wrist and Hand Dislocation
• Treatment
− Use a padded board or pillow splint with a sling
and swathe.
− Apply cold packs.
− Elevate the injured extremity.
− Administer pain medication as needed.
Finger Dislocation
• Caused by a sudden jamming force or
extension beyond normal ROM
• Signs and symptoms include:
− Pain
− Deformity
− Compromise of neurovascular structure
Finger Dislocation
• Splint entire hand in position of function.
• Do not attempt to relocate unless directed
by medical control.
• To reduce a dislocated digit:
− If dislocated to the dorsal side, extend it.
− If dislocated to the volar side, flex it.
Hip Dislocation
• Usually occur due
to deceleration
injures, in which a
flexed knee strikes
an immobile object
with extreme force
Hip Dislocation
• Conduct a full-body exam.
• Splint extremity in the position it was found.
• Perform frequent neurovascular checks.
Knee Dislocation
• Occurs as a result of high-energy trauma or
secondary to powerful twisting forces
• Signs and symptoms include:
−
−
−
−
Pain
A report that the knee “gave out”
Significant deformity
Decreased ROM
Knee Dislocation
• Assessment depends on neurovascular
function.
− Palpable pulse—splint in position found.
− No palpable pulse—reduce prior to splinting.
Tendon Lacerations,
Transections, and Ruptures
• Knee injury
− Twisting may result in
laceration, transection,
or ligament rupture.
− Compression injury
may result from a blow
to the knee.
− Hyperextension or
tension may occur.
• Shoulder injury
− Sternoclavicular
sprain results from a
blow or twisting.
− Rotator cuff injury
results from pull on
the arm, abnormal
rotation, or a fall onto
outstretched arm.
Tendon Lacerations,
Transections, and Ruptures
• Signs include:
−
−
−
−
Muscle weakness
Pain
Edema
Loss of ROM
• Splint in place.
• Apply cold packs.
• Elevate extremity.
• Assess PMS function.
Achilles Tendon Rupture
• Usually injured in start-and-stop sports
• Signs and symptoms include:
− Pain from the heel to the calf
− Inability for plantar flexion of the foot
− Possible deformity
Achilles Tendon Rupture
• Perform Thompson
test to identify.
• Management
includes:
− ICES
− Pain control
Nontraumatic Musculoskeletal
Disorders
• Patients usually do not have an acute lifethreatening condition, but there are
neurovascular concerns.
• Patients are typically already under a
physician’s care.
Bony Abnormalities
• Osteomyelitis:
Bacterial infection of
the bone
• Signs include:
−
−
−
−
−
Fever
Chills
Erythema
Swelling
Pain
• Treatment includes:
− Recognition
− Splinting
− Transport
Bony Abnormalities
• Tumor: Growth of
abnormal tissue
• Signs include:
− Pain
− Signs of infection
− Swelling or a mass of
tissue at site
• Treatment includes:
− Comparing the
extremities for
asymmetry
− Splinting
− Transport
Disorders of the Spine
• Back pain can be assessed into three
categories:
− Acute: less than 6 weeks in duration
− Subacute: from 6 to 12 weeks
− Chronic: greater than 12 weeks
Disorders of the Spine
• Assessment includes:
− Obtaining a history
− Examination of the ABCs
− Evaluation of pain levels
− Physical examination
− Neurologic and function examination
Cauda Equina Syndrome
• Caused by a spinal chord compression
• Neurologic involvement
• Signs and symptoms include:
− Urinary retention
− Loss of bowel or bladder incontinence
Spinal Stenosis
• Narrowing of the spinal canal that can occur
at single or multiple levels
• Signs and symptoms include back pain:
− Exacerbated by prolonged extension
− Relieved by rest and spinal flexion
Joint Abnormalities
• Arthritis: Inflammation of a joint
− Multiple etiologies and presentations
− Three common types:
• Osteoarthritis (OA)
• Rheumatoid arthritis (RA)
• Gout
Joint Abnormalities
• Arthritis (cont’d)
− Signs and symptoms of OA include:
• Progressive pain and stiffness
• “Cracking” or “crunching” of affected joints
− Signs and symptoms of RA include:
• Symmetric involvement of hands, feet, or wrists
• Insidious or acute onset
Joint Abnormalities
• Arthritis (cont’d)
− Signs and symptoms of gout include:
• Hot, red, swollen joint
• Decreased ROM
− Signs and symptoms of septic arthritis include:
• Patient history of IV drug use
• Presentation of toxicity, fever, and altered LOC
Joint Abnormalities
• Arthritis (cont’d)
− Treatment of OA:
• Low-impact physical therapy
• Pain control
• Joint injections
− Treatment of RA:
• NSAIDs
− Treatment of gout:
• Stabilization
• Pain relief
• Transport
Joint Abnormalities
• Slipped capital femoral epiphysis (SCFE)
− Occurs in children and adolescents
− Signs and symptoms include:
• Difficulty walking and weight-bearing
• Noticeable limp
• Pain and limited flexion and rotation at the hip
Muscle Disorders
• Myalgia: Muscle pain that is a symptom of
another underlying issue
− Short periods of intense pain in a diffuse area
− Treatment includes:
• Rest
• Administration of NSAIDs
Overuse Syndromes
• Tendinitis: Tendon becomes inflamed.
• Bursitis: Bursa becomes painful and
inflamed.
• Treatment includes:
− ICES
− Pain medication
Overuse Syndromes
• Carpal tunnel syndrome: Median nerve is
compressed where it passes carpal canal.
• Cubital tunnel syndrome: Ulnar nerve is
compressed at the cubital tunnel.
Overuse Syndromes
• Carpal/cubital tunnel syndrome treatment
includes:
− Recognition, splinting, and transport
− Rest of affected extremity
− Removal of underlying cause
Overuse Syndromes
• Polyneuropathy
− Occurs when there is simultaneous dysfunction
of multiple peripheral nerves
− Symptoms can be motor, sensory, or both.
Overuse Syndromes
• Polyneuropathy (cont’d)
− Guillan-Barre syndrome
• Inflammation and demyelination of peripheral
nerves
− Poliomyelitis
− Asymmetric paralysis of lower extremities
− Does not include sensory loss
Soft-Tissue Infections
• Myositis: Inflammation of the muscle
− Signs and symptoms include:
• Signs of infection
• Muscle weakness
• Fatigue on exertion
− Treatment is based on presentation.
Soft-Tissue Infections
• Fasciitis: Inflammation of the fascia
− Signs and symptoms include:
• History of vector transmission
• Red or warm skin
• Night sweats/chills
• Vomiting/diarrhea
− Transport to the hospital for diagnosis.
Soft-Tissue Infections
• Gangrene: Caused when the blood supply
to tissue is interrupted or stopped
− Characterized by a bad odor
− Late signs include discoloration of limbs.
− Take standard precautions, and transport
rapidly.
Soft-Tissue Infections
• Paronychia: Bacterial infection of the hand
− Spreads to circulatory and lymphatic systems
− Characterized by a small pustule or redness
− Transport for antibiotic treatment and/or lancing
of abscesses.
Soft-Tissue Infections
• Flexor tenosynovitis of the hand: Caused by
infection resulting from penetrating trauma
− Signs and symptoms include:
• Limited mobility
• Swelling
• Redness
• Transport for treatment.
Summary
• Injuries and complaints related to the
musculoskeletal system are one of the most
common reasons that patients seek medical
attention.
• Musculoskeletal injuries are sometimes very
dramatic, but attention should not be
focused on them until life-threatening
conditions have been addressed.
Summary
• You have a vital role in reducing the
complications associated with
musculoskeletal injuries by promptly and
effectively splinting injured extremities.
• Assume the existence of a fracture
whenever a patient who reports a
musculoskeletal injury has deformity,
bruising, decreased range of motion, or
swelling.
Summary
• Always perform and record an accurate
neurovascular examination before and after
splinting an injured extremity.
• Check penetrating injuries for underlying
fractures or other musculoskeletal injury.
• Musculoskeletal injuries are likely to be
accompanied by hemorrhage.
Summary
• When a dislocation is associated with
absent distal pulses, obtain medical
direction to determine whether the injury
should be reduced.
• Look for injuries to the chest and abdomen,
and fully stabilize the spine when patients
have evidence of a high-energy injury.
Summary
• Because fractures may be associated with
significant blood loss, resuscitation with IV
fluid may be necessary.
• Pelvic fractures are potentially lethal.
• Posterior sternoclavicular joint dislocations
are potentially fatal.
• Never forget the ABCs!
Summary
• Children’s bones contain weak growth
plates, making them more susceptible to
fractures than sprains.
• Remember to consider whether the MOI
suggests possible abuse.
• Musculoskeletal injuries can lead to
numerous complications.
Summary
• Blood vessels can be damaged following a
musculoskeletal injury.
• Neurovascular injuries include impalement
or laceration of nerves of a plexus, leading
to a neurologic deficit.
• Compartment syndrome occurs when
bleeding or swelling increases to the point
that the pressure within that compartment
impairs circulation.
Summary
• Crush syndrome occurs when a prolonged
compressive force impairs muscle
metabolism and circulation.
• Nontraumatic musculoskeletal disorders
can be highly complex, encompassing
aspects of rheumatology, neurology,
oncology, hematology, and infectious
diseases.
Summary
• Slipped capital femoral epiphysis (SCFE) is
a problem in the hip that affects the
epiphysis of the femur.
• Types of arthritis include osteoarthritis,
rheumatoid arthritis, gout, and septic
arthritis.
• Muscle disorders include myalgia and
myositis.
Summary
• Tendinitis and bursitis occur from frequent,
repetitive use that results in inflammation.
• Paramedics may encounter patients with
numbness, tingling, or pain in their wrist or
hand. This can be from carpal tunnel or
cubital tunnel syndrome.
• Polyneuropathy, or peripheral nerve
syndrome, stems from actual nerve damage
of the peripheral nervous system.
Summary
• Soft-tissue infections include fasciitis,
gangrene, paronychia, and flexor
tenosynovitis of the hand.
• Fasciitis is inflammation of the fascia.
• Gangrene is caused when blood supply to
tissue is interrupted or stopped.
• Paronychia is a bacterial infection located
near the nail plate.
Summary
• Flexor tenosynovitis of the hand is caused
by an infection that is usually the result of
penetrating trauma to the hand.
Credits
• Chapter opener: © Mark C. Ide
• Backgrounds: Orange – © Keith Brofsky/Photodisc/Getty
Images; Gold – Jones & Bartlett Learning. Courtesy of
MIEMSS; Blue – Courtesy of Rhonda Beck; Purple –
Jones & Bartlett Learning. Courtesy of MIEMSS.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for Emergency
Medical Services Systems, or have been provided by the
American Academy of Orthopaedic Surgeons.