Musculoskeletal Trauma

1
Musculoskeletal Trauma

• EMS Professions
• Temple College

2
Incidence/Mortality/Morbidity

• Occur in 70-80 of all multi-trauma patients
• Blunt or Penetrating
• Upper extremity rarely life-threatening
• may result in long-term impairment
• Lower extremity associated with more severe
  injuries
  
• possibility of significant blood loss
• femur, pelvic injuries may pose life-threat

3
Incidence/Mortality/Morbidity

• Problem is not just the bone injury
• Other injuries caused by the injured bone
• Soft tissue
• Vascular
• Nervous system
• Decreased function

4
Prevention Strategies

• Sports Training
• Seat Belt use
• Child Safety Seat use
• Airbag use
• Gun Safety and Education
• Motorcycle education and protective equipment
• Fall prevention
• Can you think of others?

5
Musculoskeletal System Function

• Scaffolding/Support
• Protection of vital organs
• Locomotion
• Production of RBC
• Storage of minerals

6
Musculoskeletal Structures

• Skin
• Muscles
• Bones
• Tendons
• Ligaments
• Cartilage

7
Musculoskeletal Structures - Skin

• Holds all structures together
• Barrier function
• Protects underlying structures
• Subcutaneous tissue
• Fat
• Fascia
• Further discussion in Soft-Tissue Trauma

8
Musculoskeletal Structures -Muscle

• Composed of specialized cells with ability to
  contract
  
• Voluntary (Skeletal)
• Conscious control
• Allows mobility
• Smooth (Bronchi, GI tract, blood vessels)
• Controlled by ANS
• Able to alter inner lumen diameter
• Cardiac
• Contracts rhythmically on its own

9
Musculoskeletal Structures -Muscle

• Can only contract
• Skeletal muscle causes movement by shortening
  resulting in pulling on bones through cord like
  bands

10
Musculoskeletal Structures

• Tendons
• Bands of connective tissue binding muscles to
  bones
  
• Cartilage
• Connective tissue covering the epiphysis
• Surface for articulation
• Ligaments
• Connective tissue supporting joints
• Attach bone ends to each other

11
Bones

• Living tissue
• Consists of cells which deposit calcium,
  phosphorus on protein matrix
  
• Constantly remodels itself
• Able to repair damage without formation of scar
  tissue

12
Bones

• Structural form for body
• Protection
• Point of attachment for tendons, ligaments,
  cartilage and muscles
  
• Allows for movement
• Storage of minerals
• Produce red blood cells

13
Skeletal System Components

• Axial Skeleton
• forms the central axis of the body
• includes skull, vertebral column, bony thorax
• Appendicular Skeleton
• limbs
• Pectoral girdle
• bones that attach the upper limbs to the axial
  skeleton
  
• Pelvic girdle
• paired bones of the pelvis that attach the lower
  limbs to the axial skeleton and sacrum

14
Long Bone Anatomy

• Diaphysis
• Long, narrow shaft
• Dense, compact bone
• Metaphysis
• Head of bone
• Between epiphysis and diaphysis
• Medullary canal
• Contains marrow

15
Long Bone Anatomy

• Periosteum
• Outer fibrous covering
• Allows for increase in diameter
• Vascular
• Nerves
• Epiphysis
• Articulated, widened end
• Allows bone to lengthen
• Cancellous bone with red blood marrow
• Weakest point in childs bone

16
Joints

• Points of articulation between bones
• Fused/Fibrous
• Sutures
• Between bones of skull
• Synovial
• Fluid filled chamber which lubricates articulated
  surfaces
  
• Allow for movement
• gliding, flexion, extension, abduction,
  adduction, circumduction, rotation

17
Synovial Joints

• Ball/Socket
• Shoulder/Hip
• Hinge
• Elbow/Knees/Fingers/TMJ
• Pivot
• Between radius and ulna
• Gliding
• Bones of wrist

18
Fracture

• Break in continuity of bone
• Closed
• Overlying skin intact
• Open
• Wound extends from body surface to fracture site
• Produced either by bones or object that caused
  Fx
  
• Danger of infection
• Bone end not necessarily visible

19
Mechanism of Injury

• Direct
• Break occurs at point of impact
• Indirect
• Force is transmitted along bone
• Injury occurs at some point distant to point of
  impact
  
• Femur, hip, pelvic fracture due to knees hitting
  dash

20
Mechanism of Injury

• Twisting
• Distal limb remains fixed
• Proximal part rotates
• Shearing, fracturing occur
• Football. skiing accidents
• Avulsion
• Muscle and tendon unit with attached fragment of
  bone ripped off bone shaft

21
Mechanism of Injury

• Stress
• Occur in feet secondary to prolonged running or
  walking
  
• Pathological
• Result of Fx with minimal force
• Cancer, osteoporosis

22
Fracture Descriptions

• Open vs Closed
• X-Ray descriptions
• greenstick
• oblique
• transverse
• comminuted
• spiral
• impacted
• epiphyseal

23
Fracture Types

• Transverse
• Cuts shaft at right angle to long axis
• Often caused by direct injury
• Greenstick
• Pliable bone splinters on one side without
  complete break
  
• Occurs in children

24
Fracture Types

• Spiral
• Fx site coils through bone like spring
• Occurs with torsion
• Oblique
• Occurs at angle to long axis of shaft
• Comminuted
• Bone broken into 3 or more pieces

25
Fracture Type

• Impacted
• Bone ends jammed together
• Occurs with compression
• Frequently no loss of function

26
Problems Associated with Musculoskeletal Injuries

• Hemorrhage
• Interruption of Blood Supply
• Disability
• Instability
• Soft Tissue injury

27
Complications associated with Fractures

• Hemorrhage
• Possible loss within first 2 hours
• Tib/Fib - 500 ml
• Femur - 500 ml
• Pelvis - 2000 ml
• Interruption of Blood Supply
• Compression on artery
• decreased distal pulse
• Decreased venous return

28
Complications associated with Fractures

• Disability
• Diminished sensory or motor function
• inadequate perfusion
• direct nerve injury
• Specific Injuries
• Dislocation
• Amputation/Avulsion
• Crush Injury (soft tissue trauma discussion)

29
Sprains/Strains

• Sprain
• tearing of ligaments surrounding joint
• Strain
• overstretching of muscle or tendon

30
Musculoskeletal Assessment

• The possibilities
• Life-threatening injuries or conditions,
  including life/limb threatening musculoskeletal
  trauma
  
• Life/Limb threatening injuries and only simple
  musculoskeletal trauma
  
• Life/Limb threatening musculoskeletal trauma and
  no other life/limb threatening injuries
  
• Only isolated, non-life/limb threatening injuries

31
Musculoskeletal Assessment

• Initial Assessment
• ABCDs
• Life threats managed first
• Dont overlook life/limb threatening
  musculoskeletal trauma
  
• Dont be distracted by gross but non-life/limb
  threatening musculoskeletal injury

32
Musculoskeletal Assessment

• With few exceptions orthopedic injuries are not
  life threatening.
  
• Do not let drama of obvious or grossly deformed
  fracture distract you from more serious problems
  involving ABCs

33
Musculoskeletal Assessment

• The six Ps of musculoskeletal assessment
• Pain
• on palpation
• on movement
• constant
• Pallor - pale skin or poor cap refill
• Paresthesia - pins and needles sensation
• Pulses - diminished or absent
• Paralysis
• Pressure

34
Musculoskeletal Assessment

• Vascular injury should be suspected in all
  Fxs/dislocations UPO
  
• Evaluate with 5 Ps
• Pain
• Pallor
• Pulselessness
• Paresthesias
• Paralysis

35
Musculoskeletal Assessment

• History of Present Injury
• Where is pain felt?
• What occurred? What position was limb in?
• Were deceleration forces involved?
• Was there direct impact?
• Has there ever been previous trauma or Fx?

36
Musculoskeletal Assessment

• Palpation and Inspection
• Swelling/Ecchymosis
• Hemorrhage/Fluid at site of trauma
• Deformity/Shortening of limb
• Compare to other extremity if norm is questioned
• Guarding/Disability
• Presence of movement does not rule out fracture

37
Musculoskeletal Assessment

• Palpation and Inspection
• Tenderness
• Use two point fixation of limb with palpation
  with other hand.
  
• Tenderness tends to localize over injury site.
• Crepitus
• Grating sensation
• Produced by bones rubbing against each other.
• Do not attempt to elicit.

38
Musculoskeletal Assessment

• Palpation and Inspection
• Exposed bones
• Fx can be open without exposed bones
• Principal danger is not to bones, but to
  underlying neurovascular structures around bone.

39
Musculoskeletal Assessment

• Palpation and Inspection
• Distal to injury, assess
• skin color
• skin temperature
• sensation
• motor function
• If uncertain, compare extremities
• When in doubt splint!

40
Musculoskeletal Assessment

• Because orthopedic injuries have low priority in
  multiple systems trauma, all Fxs may not be
  found in field
  
• Long Board
• Splints every bone and joint
• No loss of time
• Focus on critical conditions

41
Key Point

• Orthopedic injuries are seldom immediately life
  threatening.
  
• Tend to other issues first.
• Only immediately life threatening orthopedic
  injury is Pelvic Fx due to potential massive
  hemorrhage

42
Key Point

• The problem is not the damage to the bone
• The problem is the damage the bone does to the
  surrounding soft tissues.
  
• Evaluate Neurovascular Function Distally

43
Management - General

• Immobilization Objectives
• Prevent further damage to nerves/blood vessels
• Decrease bleeding, edema
• Avoid creating an open Fx
• Decrease pain
• Early immobilization of long bone fractures
  critical in preventing fat embolism

44
Management - General

• Principles of Fracture Management
• Splint joint above, below
• Splint bone ends
• Loosely cover open fracture sites
• Neurovascular assessment
• before and after splinting
• Gentle in-line traction of long bone
• maintain normal alignment if possible
• reduction of angulated fracture site

45
Management - General

• Principles of Fracture Management (cont)
• Position of function
• Pain management
• Body Splinting
• In urgent patient, entire body is stabilized by
  using a long board
  
• Lower extremity fractures can be splinted as one
  to the long board

46
Management - General

• Pain Management
• Avoid pain management until head/thoracic injury
  is ruled out
  
• Appropriate for isolated musculoskeletal injuries
  (fracture/sprain/dislocation)
  
• Underutilized
• Morphine sulfate titrated to pain relief without
  compromising adequate BP and ventilations

47
Management - Pediatric

• Green stick Fx may go unrecognized
• Fx can occur in epiphyseal plate, early closure
  can prevent further growth of affected bone
  
• If no explanation from patient or parents or
  injury does not follow mechanism, suspect child
  abuse.

48
Management Error

• Oversight of volume loss when evaluating pt with
  multiple Fxs
  
• Estimate blood loss at each Fx site
• Evaluation of neurovascular deficiencies in
  distal extremity

49
Dislocations

• Displacement of bone end from articulating
  surface at joint
  
• Pain or pressure is most common symptom
• Principal sign is deformity
• May experience loss of motion of joint

50
Dislocations

• Nerves, blood vessels pass very close to bone.
  Pressure on these structures can occur
  
• Checking distally essential
• Pulse presence
• Pulse strength
• Sensation

51
Management - Dislocations

• Principles of fracture/dislocation management
• Usually splinted in position of injury
• Neurovascular assessment before, after splinting
• Attempt realignment of dislocations if
• distal circulation is impaired
• long transport
• Discontinue realignment if pain increased
  significantly or resistance is encountered
  
• Immobilize proximal. distal joints and bones
• Analgesia, possible cold application

52
Sprains

• Stretching. tearing of ligaments surrounding
  joint
  
• Occur when joint is twisted beyond normal range
  of motion
  
• Most common Ankle

53
Sprain Management

• Characteristics
• Pain
• Tenderness
• Swelling
• Discoloration
• Typically does not manifest deformity
• Ice, compression, elevation, immobilize
• When in doubt, splint
• Consider analgesia

54
Strains

• Tearing, stretching of musculotendonous unit.
• Spasm, pain on active movement
• Usually no deformity, swelling
• Pain present on active movement
• Avoid active movement, weight bearing

55
Minor Musculoskeletal Injury Management

• Cold/Heat application
• cold best if in first 48 hours to reduce
  swelling
  
• heat best if after 48 hours to increase
  circulation
  
• no direct application to soft tissue
• wrap in towel or gauze

56
Minor Musculoskeletal Injury Management

• Other care
• Is immobilization/splinting needed?
• Is an X-ray needed?
• Is there a need for MD follow? ED visit?
• What type of transport is needed?

57
Traumatic Amputation

• First priority - ABCs
• Bleeding from stump usually not a problem
• Next priority is to save limb

58
Traumatic Amputation Management

• Control Bleeding
• Elevate
• Apply direct pressure to stump
• Avoid tourniquet except as last resort

59
Traumatic Amputation - Limb Management

• Place in saline moist gauze
• Place in plastic bag
• Place bag on ice
• Do not
• Warm amputated part
• Place part in water
• Place directly on ice
• Use dry ice

60
Upper Extremity Fx

• Proximal Humerus
• Usually from a fall on outstretched hand.
• Manage with sling, swathe
• Deltoid bulge often accentuated
• Shaft of Humerus
• Usually obvious due to deformity
• Wrist drop may occur
• Vascular compromise may be present

61
Upper Extremity Fx

• Colles Fx (silver fork)
• Distal radius
• Usually secondary to fall on outstretched hand
• Common in children

62
Shoulder Dislocation

• Realignment
• One attempt if neurovascular compromise
• Do not attempt if associated with other severe
  injuries or spine injuries
  
• Provide analgesia
• Pull into anatomical position
• Splinting
• Be creative
• Sling, swathe if possible
• Cravats are our friends!

63
Hip Dislocation

• Anterior
• Blow to abducted leg, external rotation of
  affected extremity
  
• Posterior
• Blow to flexed/Abducted knee
• More severe than anterior dislocation
• Associated with rupture of joint capsule,
  acetabular Fx, sciatic nerve injury

64
Management - Hip Dislocation

• Realignment
• One attempt if severe neurovascular compromise
• Do not attempt if associated with other severe
  injuries
  
• Provide analgesia
• Steady and slow pull along shaft of femur
• If successful, pops into joint, sudden relief
  of pain, leg can easily return to extension
  
• Immobilization
• Flexion of hip/knee for comfort acceptable

65
Pelvic Fracture

• Direct or indirect force
• Pelvic ring tends to break in two places
• Bone fragments can cause damage
• Major vessels
• Urinary bladder
• Rectum resulting in contamination
• Nerves (Lumbrosacral plexus or sciatic)

66
Pelvic Fx Management

• Treat as potential critical trauma patient
• Comfortable position if possible
• Splint Minimize movement
• Scoop stretcher
• Body to long board
• MAST for splint
• Replace volume prn
• Possible 4000cc blood loss
• 2 IV of LR

67
Femur Fx

• Femoral Neck (Hip)
• Most common in mid to late 60s age group.
• Leg tends to rotate outward
• looks like anterior hip dislocation
• Minimal blood loss tends to occur due to joint
  capsule
  
• Management
• NO traction splint
• long board, scoop or MAST

68
Femur Fx

• Mid-Shaft
• Result from torsion in very young or old
• High speed deceleration with impact
• Hypovolemic shock
• Fat Embolism
• Early immobilization with traction splint will
  help prevent
  
• 1000 to 2000 cc blood loss

69
Femur Fx - Management

• Assess for traction splint contraindications
• May use PASG, secure to long board
• Secure to opposite extremity and then to long
  board (premise for the Sager splint)
  
• Assess for
• Soft tissue, vascular, or nerve injury
• Assess for hypovolemia

70
Femur Fx - Management

• Traction Splints
• Used on mid-shaft femur fractures
• Do not use if suspected fracture involves
• proximal or distal 1/3 of femur
• pelvis
• hip (or hip dislocation)
• knee (or knee dislocation)
• ankle (or ankle dislocation)
• What if time (patient instability) does not allow
  for traction splint application?

71
Lower Extremity Fx

• Patellar
• Due to direct impact
• Tibia/Fibula
• High potential for
• Open fracture
• Hemorrhage
• Infection
• Calcaneal
• Results from falls (foot landing)
• High incidence of lumbar sacral compression

72
Management - Lower Extremity Fx

• Patellar, Tibia/Fibula, and Calcaneal
• Assess for neurovascular impairment
• Realign long bones
• Splinting possibilities
• board splint or cardboard splint
• vacuum splint
• pillow

73
Elbow Dislocation

• Presentation
• High neurovascular traffic
• Volkmanns contracture - ischemia secondary to
  trauma causes ischemic contractions
  
• Management
• assess for neurovascular impairment
• sling
• swathe
• analgesia and position of comfort

74
Knee Dislocation

• Presentation
• Trauma to popliteal artery
• Many reduce spontaneously
• Knee dislocation has a 50 incidence of
  associated vascular injury
  
• Presence of distal pulse does not rule out
  vascular injury
  

75
Management - Knee Dislocation

• Management
• Assess for neurovascular impairment
• One attempt at realignment if impairment or
  delayed transport
  
• Do not realign if associated with other severe
  injuries
  
• analgesia and position of comfort
• gentle, steady traction to move into normal
  position
  
• success by pop into joint, less deformity and
  pain, and increased mobility

76
Hemorrhage Management

• Direct Pressure
• Most effective method
• Pressure bandage
• Elevation
• Combination with direct pressure
• Pressure Point
• Brachial, Femoral, Carotid
• Tourniquet
• last resort
• rarely required

77
Tourniquet

• Last resort, but do not wait too long.
• Use flat wide material
• BP cuff
• Close to the wound as possible
• Do not remove
• Leave in plain view
• Note time applied and clearly communicate during
  transfer of care