Division 3

Trauma Emergencies

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Chapter 22 Musculoskeletal Trauma

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Topics
Introduction to Musculoskeletal Trauma Anatomy and Physiology of the Musculoskeletal System Pathophysiology of the Musculoskeletal System Musculoskeletal Injury Assessment Musculoskeletal Injury Management
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Introduction to Musculoskeletal Injuries

Millions of Americans experience annually Multiple MOI
Falls, crashes, violence, etc. Multi-system trauma

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Musculoskeletal System

Skeletal Tissue and Structure
Give the body its structural form Protect vital organs Promote efficient movement despite the forces of gravity Store salts and other materials needed for metabolism Produce red blood cells
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal System
Bone Structure
Diaphysis Epiphysis
End of a long bone Between epiphysis and diaphysis Growth plate Contains bone marrow

Metaphysis

Medullary canal Periosteum Cartilage

Fibrous covering of diaphysis

Connective tissue that provides a smooth articulation surface for other bones
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Musculoskeletal System

Joint Structure
Joint
Where bones interact

Synarthrosis
A joint that does not permit movement

Diarthroses (synovial joints)

Monaxial: hinge or pivot joints Biaxial: gliding, sliding, or saddle joints Triaxial: ball and socket joints

Ligaments Joint capsule

Synovial fluid
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Joint Structure (1 of 2)

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Joint Structure (2 of 2)

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Musculoskeletal System (1 of 3)

Skeletal Organization
206 bones Axial skeleton
Head, thorax, and spine

Appendicular skeleton
Upper extremities Lower extremities

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Musculoskeletal System (2 of 3)

Bone Aging
Birth to adult (1820)
Transition from flexible to firm bone

Adult to elderly (40+)

Reduction in collagen matrix and calcium salts Diminution of bone strength Spinal curvature

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Anatomy and Physiology of the Musculoskeletal System (3 of 3)

Types of Muscles
Smooth Striated Cardiac

Muscular Tissue and Structure

600 muscle groups

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Muscles

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal System

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of the Musculoskeletal System (1 of 5)

Muscular Injury Contusion Compartment Syndrome Penetrating Injury Fatigue Muscle Cramp Muscle Spasm Strain
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of the Musculoskeletal System (2 of 5)

Joint Injury
Sprain Subluxation Dislocation

Bone Injury
Open fracture Closed fracture Hairline fracture Impacted fracture Transverse
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of the Musculoskeletal System (3 of 5)

Pediatric Considerations
Flexible nature

Geriatric Considerations
Osteoporosis

Pathological Fractures
Pathological diseases

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of the Musculoskeletal System (4 of 5)

General Considerations with Musculoskeletal Injuries
Neurological compromise Decreased stability Muscle spasm

Bone Repair Cycle

Osteocytes produce osteoblasts Deposition of salts Increasing strength of matrix
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Pathophysiology of the Musculoskeletal System (5 of 5)

Inflammatory and Degenerative Conditions
Bursitis Tendonitis Arthritis
Osteoarthritis
Degenerative

Rheumatoid arthritis
Chronic, systemic, progressive, debilitating

Gout
Inflammation of joints produced by accumulation of uric acid crystals
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Assessment (1 of 2)

Scene Size-up
Clues to specific injuries. Pelvic fractures or bilateral femur fractures are Load and Go. Control major bleeding. History may suggest other injuries.

Initial Assessment
Categories of urgency
Life- and limb-threatening injury Life-threatening injury and minor musculoskeletal injury Non-life-threatening injuries but serious musculoskeletal injuries Non-life-threatening injuries and only isolated minor musculoskeletal injuries
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Assessment (2 of 2)

Rapid Trauma Assessment
Only press on pelvis if no clinical signs of injury are present such as pain.

Focused H&P
6 Ps: Pain, Pallor, Paralysis, Paresthesia, Pressure, Pulses

Detailed Physical Exam Ongoing Assessment Sports Injury Considerations

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Detailed Exam of Extremities

Deformity Contusions Abrasions Penetrations Burns Tenderness Lacerations Swelling

Also check PMS.

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management (1 of 2)

General Principles
Protecting open wounds Positioning the limb Immobilizing the injury Checking neurovascular function
Pulse
Palpate Utilize pulse oximetry

Motor Sensation
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management (2 of 2)

Splinting Devices
Rigid splints Formable splints
Vacuum splints Air splints

Soft splints Traction splints Other splinting aids

Cravats or Velcro splints

Fracture Care Joint Care Muscular and Connective Tissue Care

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Care for Specific Fractures (1 of 4)

Pelvis
Scoop stretcher Pelvic sling device
PASG as a reserve device only

Fluid resuscitation

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Care for Specific Fractures (2 of 4)

Femur Fractures
Traction splints
Contraindicated in hip/knee injuries

PASG High-force injury High potential for shock

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Care for Specific Fractures (3 of 4)

Tibia-Fibula Fractures
Frequently open fractures. Cover bone ends with moist dressing. Depending on level of fracture, use:
Rigid splint Air splint Pillow

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Care for Specific Fractures (4 of 4)

Clavicle
Most frequently fractured bone in the body Transmitted to 1st and 2nd rib Alert for lung injury

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management

Care for Specific Joint Injuries
Hip Knee Ankle Foot Shoulder Elbow Wrist/Hand Finger

Be alert for neurological compromise.

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hip Fractures
Common in the elderly. May be able to support weight.
Ability to walk does not rule out fracture.

Leg often externally rotated. May refer pain to the knee. Use other leg for splint. Use vacuum mattress if available.
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hip Dislocation
Orthopedic emergency Posterior dislocation most common Hip flexed and leg rotated internally Severe pain on attempts to straighten

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hip Dislocation Management

Splint in most comfortable position. Document sensation and pulse. Prompt transport. Be alert for associated knee injuries or fractures.

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Knee Fracture or Dislocation

Orthopedic emergency Frequently causes vascular injury Dislocation associated with 50% rate of amputation of leg

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Knee Fracture or Dislocation Management

Obvious dislocation without distal pulse:
Apply gentle traction along the long axis of the joint.

If gentle traction does not restore the pulse:

Splint in place.

Prompt transport.
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Foot or Hand Injury

Common industrial injury. Often disabling. Rarely life threatening. Splint foot with pillow. Splint hand in position of function.

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Shoulder Injury
AC Separation
Sling and swathe.

Shoulder Dislocation
Use pillow with sling and swathe.

Fracture
Use sling and swathe.

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Elbow Injury
Fracture or dislocation may cause neurovascular injury. Splint in position found. Transport promptly.

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Forearm/Wrist Injury
Rigid Splint
Keep hand in position of function.

Air Splint
May be hard to reassess circulation.

Pillow

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management

Soft and Connective Tissue Injuries
Tendon Ligament Muscle

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Medications (1 of 4)

Nitrous Oxide
50% O2:50% N2O Non-explosive Effects dissipate in 25 minutes Easily diffused into air-filled spaces in body Dose
Inhaled and self administered

Diazepam
Benzodiazepine Antianxiety Analgesic Dose
515 mg titrated

Onset
1015 minutes

Duration
1560 minutes

Onset
12 minutes

Counter agent
Flumazenil
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Medications (2 of 4)

Morphine Sulfate
Opiate alkaloid. Reduces vascular volume and cardiac preload. Do not administer to hypovolemic patients. Dose:
2 mg IVP slow

Counter agent:
Narcan
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Medications (3 of 4)

Meperidine
Demerol Narcotic analgesic Dose
50100 mg

Counter agent
Narcan

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management Medications (4 of 4)

Sublimaze
Fentanyl Synthetic opioid Equivalent to morphine Dose
2550 mg SIVP followed by an additional 25 mg as needed

Onset
Less than a minute

Duration
36 hours

Considerations
If given too rapidly, chest wall rigidity may ensue, leading to respiratory compromise.
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Musculoskeletal Injury Management

Other Injury Considerations
Pediatric musculoskeletal injury Athletic musculoskeletal injury Patient refusals and referral Psychological support

Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Summary
Introduction to Musculoskeletal Trauma Anatomy and Physiology of the Musculoskeletal System Pathophysiology of the Musculoskeletal System Musculoskeletal Injury Assessment Musculoskeletal Injury Management
Bledsoe et al., Essentials of Paramedic Care: Division 1II 2006 by Pearson Education, Inc. Upper Saddle River, NJ