Musculoskeletal Injuries

Scenario
You respond to a football field for an
“accidental injury.” Your patient is a 23-year
old male who is complaining of severe right
ankle pain. You note gross angulation and
deformity of the ankle and carefully remove
his shoe to assess his distal circulation. Your
examination reveals that there is almost no
perfusion to his foot.
YOUR SCENE
 Discussion
 What
What exam
exam findings
findings would
would lead
lead you
you to
to believe
believe that
that
perfusion
perfusion to
to the
the extremity
extremity is
is poor?
poor?

 Describe
Describe actions
actions that
that should
should be
be taken
taken immediately
immediately to
to
improve
improve blood
blood flow
flow to
to the
the foot.
foot.

 How
How will
will you
you determine
determine ifif your
your actions
actions are
are successful?
successful?

 What
What anatomical
anatomical structures
structures are
are likely
likely involved
involved in
in this
this
injury?
injury?
 Introduction to Musculoskeletal Injuries

 Millions of Americans experience annually.

 Multiple MOI
– Falls, Crashes, Violence, etc
– Multi-system trauma
 Anatomy & Physiology of the
Musculoskeletal System
 Skeletal Tissue & Structure
– Protections organs
– Allows for efficient movement
– Stores salts and other materials needed for
metabolism
– Produces RBC’s
 Pathophysiology of the
Musculoskeletal System
 Muscular Injury
 Contusion
 Compartment Syndrome
 Penetrating Injury
 Fatigue
 Muscle Cramp
 Muscle Spasm
 Strain
 Anatomy & Physiology of the
Musculoskeletal System
 Appendicular skeleton (126 bones)
– Pectoral girdle (4)
 Clavicle
 Scapula
– Upper limbs (60)
– Pelvic girdle (2)
– Lower limbs (60)
 Anatomy — Skeletal System
Bone Classifications

 Long bones

 Short bones

 Flat bones

 Irregular bones
 Anatomy — Skeletal System
Posterior view
 Anatomy & Physiology of the
Musculoskeletal System
 Bone Aging
– Birth to Adult (18-20)
 Transition from flexible to firm bone
– Adult to elderly (40+)
 Reduction in collagen matrix and calcium salts
 Diminution of bone strength
 Spinal curvature
Anatomy & Physiology of the
Musculoskeletal System
 Muscular Tissue &
Structure
– 600 muscle groups
– Types of muscles
 Smooth
 Striated
 Cardiac
 Skeletal Muscles

 Have striations

 Greater strength

 Referred to as striated
muscle

 Are under voluntary control

 Also called voluntary

muscles
 Skeletal Muscles

 Conscious control
 40% of total body mass
 Two attachments
– Origin: More fixed and proximal attachment
– Insertion: More movable and distal attachment
Contractions are rapid and forceful
 Smooth Muscles

 Walls of hollow organs  Innervated by

(e.g., urinary bladder autonomic nervous
and uterus) system
 Walls of tubes (e.g., – Regulates size of lumen
respiratory, digestive, of tubular structures
reproductive, urinary,  Contractions strong
and circulatory and slow
systems)
 Cardiac Muscles

 Have strength of  Respond to stimulation from

skeletal muscle and the nervous system
endurance of smooth
muscle
 Highly sensitive to lack of
oxygen
 Provide for movement
of blood through the  Respond to lack of oxygen
body on a continuous with pain in that area
basis (angina)
 Cardiac Muscles

 Myocardium
– Forms middle layer of heart

 Innervated by autonomic
nervous system but contracts
spontaneously without any
nerve supply

 Contractions are strong and

rhythmic
Tendons
 Bands of connective
tissue
– Bind muscles to
bones
 Allow for power of
movement across joints
 Supplied by sensory
fibers that extend from
muscle nerves
 Bursae
 Flattened, closed sacs of
synovial fluid

 Where tendon rubs against

bone, ligament, or other tendon

 Reduce friction

 Act as shock absorber

 Fill with fluid when infected or

injured
 Cartilage
 Connective tissue
covering epiphysis

 Surface for articulation

 Allows for smooth

movement at joints
Ligaments
 Connective tissue that
crosses joints
 Attaches bone to
bone
 Stretch more easily
than tendons
 Allow for stable range
of motion
 Fascia
 Dense fibrous connective tissue
 Forms bands or sheets
 Covers muscles, blood vessels, and nerves
 Supports and anchors organs to nearby
structures
 Pathophysiology of the
Musculoskeletal System
 Joint Injury  Bone Injury
– Open Fracture
– Sprain
– Closed Fracture
– Subluxation
– Hairline Fracture
– Dislocation
– Impacted Fracture
 TERMS
 Subluxation – An incomplete dislocation
 Luxation – A complete dislocation
 Crepitus – A grating sound associated with
rubbing of bone fragments.
 Angulated fracture – A broken bone where there
is a departure from a straight bone
 Fracture dislocation – An injury in which the joint
is dislocated and a part of the bone near the joint
fractures
 Pathophysiology — Mechanism of
Injury
Five forces cause bone and joint injury

 Direct force

 Indirect force

 Twisting force

 Pathological

 Fatigue
 Classifications of Musculoskeletal
Injuries
 Injuries include:
– Fractures
– Sprains
– Strains

 Joint dislocations
 Musculoskeletal Injuries
 Direct trauma
– Blunt force applied to an extremity

 Indirect trauma
– Vertical fall that produces spinal fracture distant from site
of impact

 Pathological conditions
 Some forms of arthritis
 Malignancy
 Pathophysiology — Fractures

Unstable — Proximal Fracture with dislocation

and distal ends move — Fracture at joint with
freely in relationship injury to supporting
to each other structures
 Impacted — Jammed
Open — Skin is open, together so there is no
allowing introduction movement between
of bacteria, dirt, and proximal and distal
other foreign bodies bones

Closed — Skin is intact

 Fractures
 Break in continuity of bone or cartilage

 Complete or incomplete
– Line of fracture through bone

 Open or closed
– Integrity of skin near fracture site
 Classification of Fractures
 Open

 Closed

 Comminuted

 Greenstick

 Spiral
Pathophysiology — Fractures
Impacted
Pathophysiology — Fractures
 Compartment Syndrome

– Muscle enclosed in tough non-stretchable

membrane
– Pressure builds from bleeding
– Applied to blood vessels and nerves
– Circulation impossible
– Develop over a period of hours (6Ps)
– Gangrene (Long Term)
 Joint Dislocations
 Normal articulating ends of two or more bones are displaced
– Luxation: Complete dislocation
– Subluxation: Incomplete dislocation
 Frequently dislocated joints

 Suspect joint dislocation when joint is deformed or does not

have normal range of motion

 Dislocations can result in great damage and instability

Pathophysiology — Fractures
Dislocation - Angulated
Pathophysiology — Fractures
Sprains
 Partial tearing of ligament
 Caused by sudden twisting
or stretching of joint
beyond normal range of
motion
 Common in ankle and
knee
 Graded by severity
– First-degree sprain
– Second-degree sprain
– Third-degree sprain
Strains
 Injury to muscle or its
tendon
 Overexertion or
overextension
 Common in back and arms
 May have significant loss
of function
 Severe strains may cause
avulsion of bone from
attachment site
Pathophysiology of the Musculoskeletal
System
 Inflammatory & Degenerative Conditions
– Bursitis
– Tendinitis
– Arthritis
 Osteoarthritis
– Degenerative
 Rheumatoid Arthritis
– Chronic, systemic, progressive, debilitating
 Gout
– Inflammation of joints produced by accumulation of uric acid
crystals
 Bursitis
 Inflammation of bursa
– Small, fluid-filled sac
acts as cushion at a
pressure point near
joints
– Most important bursae
are around knee, elbow,
and shoulder
 Bursitis
 Bursitis is usually from:
– Pressure
– Friction
– Injury to membranes surrounding the joint
 Treatment
– Rest, ice, and analgesics
Tendonitis
 Inflammation of tendon
– Often caused by injury

 Symptoms include:
– Pain
– Tenderness
– Restricted movement of muscle
attached to affected tendon

 Treatment
– Nonsteroidal antiinflammatory
drugs (NSAIDs)
– Corticosteroid medications
 Arthritis
 Joint inflammation
– Pain, swelling, stiffness, and redness

 Joint disease
– Involving one or many joints
– Many causes

 Varies in severity
– Mild ache and stiffness
– Severe pain and later joint deformity
 Arthritis
 Osteoarthritis
(degenerative arthritis)
most common

 Pain usually managed

with antiinflammatory
agents
 Extremity Trauma
 Signs and symptoms – False movement
– Pain on palpation or (unnatural movement
movement of extremity)
– Swelling, deformity – Decreased or absent
sensory perception or
– Crepitus
circulation distal to
– Decreased range of injury
motion
 Six "P"s of Compartment
Syndrome
1. Pain
– On palpation (tenderness)
– On movement
2. Pallor—pale skin or poor capillary refill
3. Paresthesia—pins and needles
sensation
4. Pulses—diminished or absent
5. Paralysis—inability to move
6. Pressure
 Associated Complications
 Hemorrhage  Interruption of blood
supply
 Instability
 Nerve damage
 Loss of tissue

 Simple laceration  Long-term disability

and contamination
 Blood Loss
Concerns
 Pelvis  Rib
– Per BTLS: 2 units (1 – Pneumothorax (can
litter) to loss of bleed up to 3 liters per
complete blood volume pleural cavity)
(5 liters) or 500 ml per
fracture
 Be prepared to treat
 Femur hemorrhagic shock
– Per BTLS: 2 units (1
liter) per fracture
 Assessment
 Determine if life-threatening conditions are
present
– Care for those first
 Never overlook musculoskeletal trauma
 Don’t allow noncritical musculoskeletal
injury to distract from priorities of care
 Musculoskeletal Assessment
 Four classes of
patients
– Life-/limb-threatening
injuries or conditions
 Includes life-/limb-
threatening
musculoskeletal trauma
– Other life-/limb-threatening
injuries and simple
musculoskeletal trauma
– Life-/limb-threatening
musculoskeletal trauma
 No other life-/limb-
threatening injuries
– Isolated, non-life-/limb-
threatening injuries
 Musculoskeletal Injury Assessment
 Scene Size-up  Rapid Trauma
 Initial Assessment Assessment
– Categories of urgency  Focused H&P
 Life & Limb threatening
injury – 6 P’s: Pain, Pallor,
 Life threatening injury and
Paralysis, Paresthesia,
Pressure, Pulses
minor musculoskeletal
injury  Detailed Physical Exam
 Non-life threatening  Ongoing Assessment
injuries but serious
musculoskeletal injuries  Sports Injury
 Non-life threatening Consideration
injuries and only isolated
minor musculoskeletal
injuries
 Age-Associated Changes
in Bones
 Water content of intervertebral disks
decreases
 Increased risk of disk herniation
 Loss of stature is common – ½ - 3/4
inch
 Bone tissue disorders shorten trunk
 Age-Associated Changes
in Bones
 Vertebral column assumes arch shape

 Costal cartilages ossify, making thorax more rigid

 Shallow breathing due to rigid thoracic cage

 Facial contours change

 Fractures
 Limb -Threatening Injuries
 Knee dislocation
 Fracture or dislocation of ankle
 Subcondylar fractures of elbow
Require rapid transport
 Musculoskeletal Injury Management

 Other Injury Consideration

– Pediatric Musculoskeletal Injury
– Athletic Musculoskeletal Injury
– Patient Refusals & Referral
– Psychological Support
 Musculoskeletal Injury Management

 General Principles
– Protecting Open Wounds
– Positioning the limb
– Immobilizing the injury
– Checking Neurovascular Function
Musculoskeletal Injury Management
 Splinting Devices
– Rigid splints
– Formable Splints
– Soft Splints
– Traction Splints
– Other Splinting Aids
 Vacuum Splints
 Air Sprints
 Cravats or Velcro Splints
 Fracture Care
 Joint Care
 Muscular & Connective Tissue Care
 Musculoskeletal Injury Management
 Care for Specific Fractures
– Pelvis
 Scoop Stretcher
 PASG
 Fluid Resuscitation
– Femur
 Traction Splints
 PASG
 Fracture versus hip doslocation
 Musculoskeletal Injury Management
 Care Specific Fractures
– Tibia/Fibula
– Clavicle
 Most frequently fractured bond in the body
 Transmitted to 1st and 2nd rib
 Alert for lung injury
– Humerus
– Radius/Ulna
 Musculoskeletal Injury Management
 Care for Specific Joint Injuries
– Hip
– Knee Joint
– Ankle
– Foot
Injuries
– Shoulder
– Elbow
Alert for
– Wrist/Hand PMS
– Finger Compromis
e
Knee Dislocation/Fracture with No
Distal Pulse
 Gentle, steady traction  Should be attempted
while moving extremity if transport will be
into normal alignment greater than 2 hours
 Successful realignment (even with a pulse)
= “Pop,” loss of  Patellar dislocation –
deformity, relief of pain, Not limb threatening
increased mobility
 Provide full
immobilization
Dislocation/Fracture Realignment

Never
Never manipulate the elbow!
 Musculoskeletal Injury Management

 Soft & Connective Tissue Injuries

– Tendon
– Ligament
– Muscle
 Cold vs. Hot Therapy
 Cold Therapy
– Applied for 20 minutes periods
– First 24 hour – Reduces pain and swelling

 Hot Therapy
– After 24 hour – Increases circulation
 Musculoskeletal Injury Management
Medications
Not A Biotel Option
 Nitrous Oxide  Diazepam
– 50% O2:50% N – Benzodiazepine
– Non-explosive – Antianxiety
– Effects dissipate in 2-5 – Analgesic
minutes – Dose
– Easily diffused into air  5-15 mg titrated
filled spaces in body. – Onset
 10-15 minutes
– Dose
 Inhaled & self – Duration
administered  15-60 minutes
– Onset – Counter Agent
 1-2 minutes  Flumazenil
Dislocation of Acromioclavicular
Joint
 Humerus Injury
 Older adults and children

 Difficult to stabilize

 Complications
– Radial nerve damage if
fracture in middle or distal
portion of humeral shaft
– Humeral neck fracture may
cause axillary nerve
damage
– Internal hemorrhage into
joint
Posterior Dislocation of the Elbow
Joint with Marked Deformity
Severe Open Fracture of Forearm
Penetration of Forearm Caused by Nail
Gun
Greenstick Fracture With
Marked Deformity
Fracture of the Distal Radius
Hand Injury from a Motorcycle Crash
 Femur Injury
 Diameter of right thigh
represents increased
blood volume of 2 to 3
L
Open Fracture of the Lower Leg
Subtalar Dislocation
Foot that was Run Over by the Wheel
of a Railway Coach
Musculoskeletal Injury Management
Medications
 Oxygen
Nitrous Oxide
Morphine Sulfate
 Fluids
 Nitrous Oxide
 Class: Gaseous  Dose: Instruct patient to
Analgesic/Anesthetic inhale deeply through
 Route: Inhalation Adult patient-held mask or
Dose: Instruct patient to mouthpiece Drug
inhale deeply through  Action: Depresses the
patient-held mask or central nervous system
mouthpiece Pediatric Increases oxygen tension in
the blood thereby reducing
hypoxia Onset:2 minutes -
5 minutes Duration:2
minutes - 5 minutes
 Nitrous Oxide
 Indications: Adjunct analgesic
for ischemic chest pain Severe
pain or discomfort in all patients
without contraindications.
 Precautions: Must be self
administered Check machine
gauges daily for proper
concentrations Monitor blood
pressure and pulse oximetry
values during administration
 Side Effects:
Hypotension Dizziness Nausea
and vomiting
 Contraindications: Any altered
level of consciousness or head
injury Chronic obstructive
pulmonary disease Chest
trauma or actual/suspected
pneumothorax Abdominal
trauma Major facial
trauma Acutely psychotic
patients Pregnancy, other than
active labor Any patient (adult
or pediatric) unable to self-
administer Decompression
sickness
 Morphine Sulfate
Precautions:
Monitor respiratory status and
 Indications blood pressure closely.
Notify Biotel prior to
Pain and anxiety administration if patient is
secondary to AMI >65yrs of age, debilitated, has
Chest pain unrelieved altered mental status, or
by Nitroglycerin systolic BP<110mmHg
Pulmonary edema CHF: be prepared to intubate
Pain secondary to Antidote: Naloxone
amputations or (Narcan®)
fractures
 Morphine Sulfate
 Class: Narcotic Analgesic
Drug Action:
Route: Slow IV push Alleviates pain
  Decreases peripheral
Dose: Adult: Administer in vascular resistance -
titrated doses of 2 - 4mg, vasodilator
up to a maximum of 10mg
Pediatric: 0.1mg/kg  Decreases cardiac
workload and oxygen
demand on the heart
QUESTIONS?