Musculoskeletal Trauma :Musculoskeletal Trauma EMS Professions Temple College


Incidence/Mortality/Morbidity :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


Incidence/Mortality/Morbidity :Incidence/Mortality/Morbidity Problem is not just the bone injury Other injuries caused by the injured bone Soft tissue Vascular Nervous system Decreased function


Prevention Strategies :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?


Musculoskeletal System Function :Musculoskeletal System Function Scaffolding/Support Protection of vital organs Locomotion Production of RBC Storage of minerals


Musculoskeletal Structures :Musculoskeletal Structures Skin Muscles Bones Tendons Ligaments Cartilage


Musculoskeletal Structures - Skin :Musculoskeletal Structures - Skin Holds all structures together Barrier function Protects underlying structures Subcutaneous tissue Fat Fascia Further discussion in Soft-Tissue Trauma


Musculoskeletal Structures -Muscle :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


Musculoskeletal Structures -Muscle :Musculoskeletal Structures -Muscle Can only contract Skeletal muscle causes movement by shortening resulting in pulling on bones through cord like bands


Musculoskeletal Structures :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


Bones :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


Bones :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


Skeletal System Components :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


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


Long Bone Anatomy :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 child’s bone


Joints :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


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


Fracture :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


Mechanism of Injury :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


Mechanism of Injury :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


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


Fracture Descriptions :Fracture Descriptions Open vs Closed X-Ray descriptions greenstick oblique transverse comminuted spiral impacted epiphyseal


Fracture Types :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


Fracture Types :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


Fracture Type :Fracture Type Impacted Bone ends jammed together Occurs with compression Frequently no loss of function


Problems Associated with Musculoskeletal Injuries :Problems Associated with Musculoskeletal Injuries Hemorrhage Interruption of Blood Supply Disability Instability Soft Tissue injury


Complications associated with Fractures :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


Complications associated with Fractures :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)


Sprains/Strains :Sprains/Strains Sprain tearing of ligaments surrounding joint Strain overstretching of muscle or tendon


Musculoskeletal Assessment :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


Musculoskeletal Assessment :Musculoskeletal Assessment Initial Assessment ABCDs Life threats managed first Don’t overlook life/limb threatening musculoskeletal trauma Don’t be distracted by “gross” but non-life/limb threatening musculoskeletal injury


Musculoskeletal Assessment :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 ABC’s


Musculoskeletal Assessment :Musculoskeletal Assessment The six “P”s 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


Musculoskeletal Assessment :Musculoskeletal Assessment Vascular injury should be suspected in all Fx’s/dislocations UPO Evaluate with 5 P’s Pain Pallor Pulselessness Paresthesias Paralysis


Musculoskeletal Assessment :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?


Musculoskeletal Assessment :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


Musculoskeletal Assessment :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.


Musculoskeletal Assessment :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.


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


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


Key Point :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


Key Point :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


Management - General :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


Management - General :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


Management - General :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


Management - General :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


Management - Pediatric :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.


Management Error :Oversight of volume loss when evaluating pt with multiple Fx’s Estimate blood loss at each Fx site Evaluation of neurovascular deficiencies in distal extremity Management Error


Dislocations :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


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


Management - Dislocations :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


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


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


Strains :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


Minor Musculoskeletal Injury Management :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


Minor Musculoskeletal Injury Management :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?


Traumatic Amputation :Traumatic Amputation First priority - ABC’s Bleeding from stump usually not a problem Next priority is to save limb


Traumatic Amputation Management :Traumatic Amputation Management Control Bleeding Elevate Apply direct pressure to stump Avoid tourniquet except as last resort


Traumatic Amputation - Limb Management :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


Upper Extremity Fx :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


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


Shoulder Dislocation :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!


Hip Dislocation :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


Management - Hip Dislocation :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


Pelvic Fracture :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)


Pelvic Fx Management :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


Femur Fx :Femur Fx Femoral Neck (Hip) Most common in mid to late 60’s 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


Femur Fx :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


Femur Fx - Management :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


Femur Fx - Management :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?


Lower Extremity Fx :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


Management - Lower Extremity Fx :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


Elbow Dislocation :Elbow Dislocation Presentation High neurovascular traffic Volkmann’s contracture - ischemia secondary to trauma causes ischemic contractions Management assess for neurovascular impairment sling swathe analgesia and position of comfort


Knee Dislocation :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


Management - Knee Dislocation :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


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


Tourniquet :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