Musculoskeletal Care

Skeletal System

• 14% total body weight• Function

• Shape, Movement, Storage (Calcium, Phosphorus, Iron)

• Protection of organs• Blood cell production• Endocrine Regularion

• Components• Bones

• Mineralized osseous tissue• Cartilage

• Soft connective tissue/Collagen• Flexible support

• Tendons• Attach muscle to bone• Collagen, Elastin, Proteogylcans

• Ligaments• Attach bone to bone • Collagen

• Axial Skeleton• Skull, vertebral column, thoracic cage

• Appendicular Skeleton• Upper limbs, pelvic girdle, lower limbs

Axial SkeletonSkull

• Skull• 22 bones• Cranium + Face• Encases brain• Brain + CSF + Vessels

• Little space• Facial Bones

• Orbits• Eyes

• Nasal Bones• Maxilla

• Upper Jaw• Zygomatics

• Cheekbones • Mandible

• Lower Jaw

Axial SkeletalVertebral Column

• Function• Support

• Components • 33 Vertebrae• Intervertebral disks

• Divisions of Vertebrae• Cervical (C-) = 7 Neck

• C1 = Atlas• C2 = Axis

• Thoracic (T-)= 12 Chest• Lumbar (L-)= 5 Lower Back• Sacral (S-)= 5 Back of pelvis (fused) • Coccyx (C-)= 4 Tailbone (fused)

Axial Skeletal Thoracic Cage

• Function• Protection of thoracic cavity• Supports shoulder girdle

• Components • 12 pairs of ribs

• 1-10 attach to sternum• 11-12 “float”

• Sternum • Manubrium• Body• Xiphoid process

• Costal cartilage• Connect ribs to sternum

• Thoracic vertebrae (12)

Appendicular SkeletonUpper Extremities

• Clavicle• Scapula• Acromion (Tip of shoulder)• Humerus • Olecranon (elbow)• Radius• Ulna• Carpals (wrist)• Metacarpals (hands)• Phalanges (fingers)

Appendicular SkeletonLower Extremities

• Greater Trochanter (head of femur)• Acetabulum (socket of hip)• Femur (thigh)• Patella (knee)• Tibia (shin)• Fibula (lower leg)• Medial/Lateral malleolus (ankle)• Tarsals and metatarsals (foot)• Calcaneus (heel)• Phalanges (toes)

Appendicular SkeletonPelvis

• Function• Support and protection

• Components • Ilium

• Wings • Pubis

• Anterior portion• Ischium

• Inferior portion• Sacrum• Coccyx

Joints

• Definition• 2 or more bones connecting to bones

• Types• Ball and socket

• Hip/Shoulder• Wide Range of motion

• Hinge• Elbow/knee• Motion in 1 plane• Flexion and extension only

Types of Force

• Direct• Energy applied directly to an area• GSW shattering bone• Falling person landing on feet• Sports injuries

• Indirect• Force transmitted along axes of

bone• Injury at a location other than

point of impact• i.e. Person falling on

outstretched hand • Twisting

• Twisting force transmitted along axes of bone

• i.e. A scatter who plants skates in the middle of turn

Types of Fractures

• Fracture• A break in the continuity of a bone

• Complete• Two bone ends widely separated

• Incomplete• Hairline crack along the bone

• Open• Breakage of skin at the fracture site• Exposed to the outside

environment• Closed

• No break of the skin over the fracture site

• No environmental exposure

Open Fractures

Closed Fractures

Injuries to LigamentsTendons

• Sprains• Injuries to ligaments• Usually due to stretching forces

• Strains• Injuries to:

• Muscle• Tendons• “You can tend a strain”

• Usually due to stretching forces• Dislocation

• Displacement of a bone in joint from its normal position

• Stretching/tearing of joint ligaments must also occur

Musculoskeletal CareAssessment

• BSI/Scene Safety• Determine MOI

• Lap belt injuries- Possible abd complications• Starburst – Possible head trauma• Etc.

• Initial assessment• ABC’s• Major bleeds/Life threats• C-Spine

• Focused Hx/Px• More info on MOI• Events prior to accident

• Seatbelts worn• Airbags deployed• Did pt trip and fall• Did pt become dizzy/ALOC and fall• Etc.

• DCAP-BTLS• Vitals• On-going assessment

Seatbelt Injury

Bone/Joint InjuriesS/S

• Deformity• Angulation• Pain and tenderness

• Sometimes referred distal/proximal to injury

• i.e. Hip fx- pain in knee• Crepitus

• Bone ends rubbing against each other• Swelling

• Fluid/blood loss • Discoloration/Bruising • Exposed bone ends• Joint locked into position

• Possible dislocation • Loss of use

• Do not force movement against pt complaints

Bone/Joint InjuriesBlood Loss

• Bleeding• CAN BE LIFETHREATING COMPLICATION!• Radius or Ulna - 250-500 ml• Humerus - 500-759 ml• Pelvis - 1500-3000 ml• Femur - 1000-2000 ml• Tibia and fibula - 500-1000 ml

Bone/Joint InjuriesVascular Injuries

• Vascular Injuries • Injuries to blood vessels • Pinching, tearing, spasms,

compression, occlusion by clots

• Loss of distal blood flow • Assessment

• Distal Pulses• Skin color/temp• Capillary refill time• Pain• Numbness, Tingling,

Prickling,• Sensory loss• Paralysis distal to injury

Bone/Joint InjuriesPeripheral Nerve Injuries

• Peripheral Nerve Injuries • Injured more often than

arteries• Tearing, Pinching, Stretch,

Compression, of a nerve• S/S

• Numbness• Pain• Abnormal sensation• Loss of motor ability

• Assessment• Pulse• Motor• Sensation

Bone/Joint InjuriesInternal Organ Injuries

• Injuries to Internal Organs• Forces transmitted to underlying organs

• Thorax• Flail segment • Hemothorax• Pneumothorax

• Open • Closed• Tension

• Traumatic asphyxia • Rupture of:

• Spleen• Liver

• Pelvis• Bladder• Urethra• Rectum• Lower intestine• Reproductive organs

Bone/Joint Injuries Care

• BSI• O2• Splinting

• After life threats have been treated

• Cold pack • Reduces swelling in:• Painful• Swollen• Deformed

• Elevation of extremity

Bone/Joint InjuriesSplinting

• Reasons• Prevents motion of:

• Bone fragments• Bone ends• Angulated bones

• Minimizes:• Damage to –muscles – nerves – blood vessels• Conversion of closed fx to open fx• Compression of blood vessels due to bone ends• Excessive bleeding• Pain with movement• Paralysis of extremity due to spinal injury

Splint Types

• Sling and Swathe • Sling- Triangular bandage supporting weight of injured arm • Swathe – Triangular bandage binding upper arm to chest wall

• Rigid Splints• Rigid material often padded• Applied to both sides of injury• Secured with roller bandages or cravats

• Traction Splints• Metal frame with pulley system • Apply traction to lower extremity fx• Used for femur fx

• Pneumatic Splints (Air, Vacuum)• Plastic splints filled with air• Circumferential support

• Improvised Splints• Blankets, magazines, cardboard, notebooks, pillows, etc…

• Pneumatic Anti Shock Garment• Air splint for lower extremity/pelvis fx

General Rules of Splinting

• Assess PMS distal to injury:• Prior to• After splinting

• Immobilize the joint• Above and Below injury

• Remove clothing• Cover open wounds

• Sterile dressings• Splint joint injuries in position found

UNLESS:• If severe deformity or cyanosis:

• Align with gentle traction before splinting

• If resistance is met or pt complains of increased pain – Splint in position

• Do not intentionally replace protruding bone ends

• Cover with moistened sterile dressing

• Cover with dry sterile dressing • Pad each splint

• Prevents further pain• Splint the injury

• When in doubt…• When feasible and no life threats

• If pt in shock:• Align in normal anatomical position• TRANSPORT• Total body immobilization= Long

Back Board (LBB)

Splinting Precautions

• Compression of:• -Nerve – Tissues - Vessels

• Delay of transport• Critical pt = LBB

• Reduction of distal circulation• If applied too tight

• Aggravation of: (if too loose)• Bone/joint injury• Nerves• Vessels• Tissue

Long Bone Splinting

• Splints:• Rigid splint, Air Splint, Sling and Swathe, Long Board Splint

• Locations: • Arms and Legs

• BSI• Apply manual stabilization• Assess PMS• If severe deformity or cyanosis:

• Align with gentle traction before splinting• Measure splint• Immobilize 1 joint above and 1 joint below

• Secure ENTIRE injured extremity • Immobilize hand/foot in position of function• Reassess PMS

Measure Apply/Secure Immobilize Joint Above and Below injury

Splinting of Joints

• BSI• Manual stabilization• Assess PMS• If distal extremity lacks

pulse or is cyanotic• Align with gentle traction

if no resistance

• Immobilize site of injury• Immobilize bone above

and below injury• Reassess PMS

Traction Splinting

• Indication:• Painful, swollen, deformed mid-thigh• No joint or lower leg injury

• Contraindication:• Injury close to the knee• Injury to the knee• Injury to hip• Injured pelvis• Partial amputation

• Avulsion with bone separation• Distal limb is connected by a margin of tissue• Traction would risk separation

• Lower leg/ankle injury

Traction Splinting

• BSI• Manual stabilization• Assess PMS• Apply ankle hitch – (Ankle) = Distal immobilization• Apply manual traction • Adjust splint length to length of uninjured leg• Position splint under injured leg• Apply ischial strap –(Groin) = Proximal immobilization• Apply mechanical traction• Release manual traction• Position/secure straps

• 2 Above the knee• 2 Below the knee • DO NOT PLACE DIRECTLY OVER SITE OF INJURY

• Reassess ischial strap and ankle hitch • Reassess PMS• Secure torso to LBB

• Immobilized hip • Secure splint to LBB

• Prevents movement of splint

Manual Stabilization

Manual Traction Apply ankle hitch.

Continue manual traction

Place splint under injured leg

Apply ischial strap Apply mechanical tractionRelease manual traction

Position straps: 2 above knee, 2 below knee

Reassess PMS

That does it…

REMEMBER: ASSESS PMS BEFORE/AFTER IMMOBILIZATION