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Module9

MusculoskeletalSystem

TheSkeleton
Madeupof206bones Providesprotectionforvitalorgans+isframeworkforthebody Skeletonprovidessupport: o Supportagainstgravity o Movement o Protection o Productionsofbloodcells o Storageofcalcium+phosphorus Musculoskeletalsystemcomposedof: o Bones o Muscles o Cartilages o Tendons o Ligaments

1.1

AxialSkeleton(80bones)

Formscentral(longitudinal)axisofbody Skull(28bones) o Cranium(8Bones) o Face(14Bones) o Earbones(6Bones) Hyoidbone(1bone) Vertebralcolumn(26bones) Thoraciccage(25bones)

1.2

Appendicularskeleton(126bones)
Pectoralgirdle(4bones) o Clavicle(2bones) o Scapula(2bones) Upperlimbs(60bones) Pelvicgirdle(2bones) Lowerlimbs(60bones)

1.3

TheSkull
Madeupof22bones o 8of22bonesarecraniumbones o Craniumbonesisboxlikecavitycontainsandprotectsthebrain o 14otherbonesfromface o Facialbonesgiveitsshapeandprovideprotectionforeyes Amongbonesformingcranium o Frontal o Occipital o Parietal(2bones) o Temporal(2bones) Amongbonesformingface o Maxillary(2bones) o Mandible(2bones) o Zygomatic(2bones) o Nasalbones(2bones) InferiorNasalConchae(2bones)

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Module9

MusculoskeletalSystem

Other: LacrimalBones(2bones) PalatineBones(2bones) ZygomaticBones(2bones) AllbonesfusedorfixedtooneanotherEXCEPTmandible o Mandibleattachedtoskulloneachsidebyhingejointtoallowformovement Infancy:craniumNOTfullyformed o Donotfusetogetheruntilage+15month o Latefusionreasonwhyinfantshavetwosoftareasontheirheads o Softspotscalledanteriorandposteriorfontanelle

1.4

Spinalcolumn
Spinalcolumncentralsupportingstructureofbody Composedof33bones o Cervical(7vertebrae) Cervicalspinal:C1C7 SkullrestonC1 o Thoracic(12vertebrae) Thoracicspine:T1T12 Onepairofribsattachedtoeachvertebrae o Lumbar(5vertebrae) Lumbarspine:L1L5 Akadorsalspine o Sacrum(5vertebraefused) Sacralspinal:S1S5 Fusedtogetherformonebonecalledsacrum Sacrumjoinedtoiliacbonesofpelvis withstrongligamentsatsacroiliacjointstoformpelvis o Coccyx(4vertebraefused) Lastfourvertebraefusedformcoccyx/tailbone

1.5

TheThorax
Thorax/ribcagemadeupof12pairsofribsandsternum(breastbone) Contains+protectslungs,heart,greatvessels,trachea(windpipe),oesophagus(gullet/foodpipe) Thorax/chestcavitytwomainparts o 12pairsofribs Trueribs,falseribs,floatingribs o Sternum

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Module9 1.6

MusculoskeletalSystem

Pelvis
Bonyring Twoinnominatebones Eachbonemadeof3fusedbones o Ilium(hip) o Ischium(bumbone) o Pubis

1.7

Lowerextremities
Threemainpartsoflowerextremities o Thigh o Leg o Foot Threejointsconnectmainpartsofleg o Hip Betweenhipandthigh o Knee Betweenthighandleg o Ankle Betweenlegandfoot Bonesofthelowerextremities o Femur(Largestboneinthebodythigh) o Patella(kneecap) o Tibia(shinbone) o Fibula o Tarsals o Metacarpals o Phalanges

1.8

Upperextremities
Extendsfromshouldergirdletofingertipscomposedof: o Shouldergirdle Scapula(2) Clavicle(2) o Humerus o Radius o Ulna o Carpals o Metacarpals o Phalanges

1.9

TypesofBones
Theyarehardandstrongstructures Bonesclassifiedaccordingtoshape o Longbone Longbonesofthearmsandlegs o Shortbone Smallbonesofwristandankle o Flatbone Shoulderbladeandscalp,sternum o Irregularbone Vertebrae o Sesamoidbone Patella

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Module9

MusculoskeletalSystem

Classificationbasedonstructure: o Compactbone(hardanddense,outerbone) o Spongybone(marrow) Classificationbasedonstructure:

Importantpartsofbonesbestillustratesbyfemur Head o Roundedendmadeofcompactboneallowsforrotation Neck o Belowthehead Shaft o Longcylindricalportionofbonewithcompactbone(outerlayer)+spongymarrow(innerlayer) Condyles o Bumps/prominencesusuallyforarticulationwithanotherbone Tuberosities o Prominencesonbone Epiphysealplate o Plateofcartilageresponsibleforgrowthinlengthofbone(foundinchildren)

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Module9 1.10 Joints


MusculoskeletalSystem

Jointformedwhentwobonescomeintocontact Jointconsistsofendsofbonesandsurroundingconnectingandsupportingtissue Mostjointsinbodynamedbycombiningnamesoftwobonesthatformjoint Jointclassifications o Ballandsocket o Condyloid+saddlejoints o Gliding/Plane o Hinge o Pivot

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Module9

MusculoskeletalSystem

1.10.1 Ballandsocket
Mostfreelymoveablejoint Possiblemovements: o Flexion o Extension o Adduction o Rotation o Circumduction Hipandshoulderjoints

1.10.2 Condyloid+saddlejoints
Movementtakesplacearoundtwoaxis Permittingmovements: o Flexion o Extension o Adduction o Abduction o Circumduction o Circumduction(Combinationofabovemovements) Wrist

1.10.3 Gliding/Plane
Articularsurfacesglideovereachother Possiblemovements: o Glidemovement Sternoclavicularjoint,jointsbetweencarpalsbonesandbetweentarsalbones,jointbetweenvertebrae

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Module9 1.10.4 Hinge


Permitsmovementinoneplaneonly Possiblemovements: o Flexion o Extension Knee,Elbow,ankle

MusculoskeletalSystem

1.10.5 Pivot
Rotarymovement(allowsmovementaroundoneaxisonly) Possiblemovements: o Rotarymovement Classicexample:superior+inferiorradioulnajoints

1.11 Tendons
Tendonsareconnectivetissue Attachesmuscletobone Composedofwhitefibroustissuearrangedinverydensemanner+ofgreatstrength

1.12 Ligaments
Similarstructuretotendons Butattachbonetobone Ligamentsstrongbandsoffibroustissueservetobindtogetherbonesenteringinjoints o TheyareeitherCordlikeorflattenedbands o Thoughmostjointssurroundedbyfibrouscapsule/capsularligament

1.13 Cartilage
Cartilagealsotypeofconnectivetissue Formsthesmoothsurfaceovertheendsofthebones Cartilageprovidescushioningatjoints

1.14 Muscles
Muscleiscontractiletissue o Hasabilitytoactivelyshortenandlengthen Mostmusclesattachedtobonebymeansoftendons 3typesofmuscles(maintainpostureandallowformovement) o Skeletalmuscles(Striated) o Smooth(Involuntary) o Cardiac

1.14.1 SkeletalMuscle
Skeletalmuscleattachestotheboneoftheskeleton Formmajormusclemassofthebody CalledVoluntarymuscle o Underdirectvoluntarycontrolofbrain o Canbestimulatedtocontractandrelaxatwill AlsocalledStriatedmuscle Whenviewedundermicroscopehascharacteristicsofstripes(striations) Specificnervespassdirectlyfrombraintospinalcord o Theyconnectwithothernervesandpasstoeachskeletalmuscle o FaciaCoversallskeletalmuscles Faciaencasesthemuscletissue AteitherendofmuscleFaciaextendsbeyondmuscletoattachtobone

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Module9 1.14.2 SmoothMuscle


MusculoskeletalSystem

Involuntarymuscle o Carriesoutmuchofautonomicworkofbody Foundinwallsofmosttubularstructures o Gastrointestinaltract o Urinarysystem o Bloodvessels o Bronchioflungs

1.14.3 CardiacMuscle
Speciallyadaptedinvoluntarymuscle o Veryrichsupplybloodsupplyandownelectricalsystem Heartislargemusclecomposedoftwopumps o Unequalforce Onelowerpressure Onehigherpressure Heartfunctionscontinuouslyfrombirthtodeath CardiacmusclecantolerateinterruptionofbloodsupplyONLYFORAFEWSECONDS o Requirescontinuoussupplyofoxygen+glucosefornormalfunction Cardiacmuscleplacedinseparatecategory o Becauseofspecialstructureandfunction

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2.1

MusculoskeletalInjuries
Classification

Injuriesresultedfromtraumaticforceinclude: Strains Sprains Fractures Jointdislocations

2.2

Complications
Haemorrhage Instability Lossoftissue Simplelaceration Contamination(speciallyopenfractures) Interruptionofbloodsupply Nervedamage Longtermdisability Canresultfrom o Directtrauma Bluntforceappliedtoanextremity o Indirecttrauma Verticalfallthatcausesfracturedistantfromsiteofimpact o Pathologicconditions Tumours FormsofArthritis Malignancy

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Module9 2.2.1

MusculoskeletalSystem

Strains
Injurytomuscleoritstendon Causedbyoverexertionoroverextension Commonlyoccurinbackandarms Maybeaccompaniedbysignificantlossinfunction Severestrainsmaycauseavulsionofbonefromattachmentsite

2.2.2

Sprains
Moreeventsandsportsinjuries Partialtearingofligament Causedbysuddentwistingorstretchingofjointbeyondnormalrangeofmotion Twocommonareasforsprains o Ankles+knees Sprainsaregradedbyseverity o Firstdegreesprain o Seconddegreesprain o Thirddegreesprain

2.2.3

Jointdislocations
Occurwhennormalarticulatingendsoftwoormorebonesaredisplace o Luxationcompletedislocation o Subluxationincompletedislocation Suspectjointdislocationwhenjointisdeformed/doesnotmovewithnormalrangeofmotion Alldislocationscanresultingreatdamageandinstability

2.2.4

Arthritis
Inflammationofthejoint Characterizedbypain,swelling,stiffnessandredness Ajointdisease(involvingone/manyjoint)canoccurfrommanycauses Variesinseverityfrommildachetostiffnesstoseverepainandlaterjointdeformity Osteoarthritis(degenerativearthritis)mostcommon Painassociatedwiththisconditionusuallymanagedwithantiinflammatoryagents

2.2.5

Fractures
Breakinthecontinuityofbone/cartilage Maybecomplete/incompletedependingonlineoffracturethroughbone Maybeclassifiedasopen/closeddependingonintegrityofskinnearfracture

2.2.5.1 Classificationoffractures
o o o o o o o o o o Open Closed Comminuted(crushinginjury) Greenstick(bonesbend) Spiral Oblique(angle/slantlinefracture) Transverse(straightlinefracture) Stress(manyhairlinefractures) Pathological Epiphyseal(atthegrowthplate)

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Module9

MusculoskeletalSystem

2.2.6

Extremitytrauma

Commonsignsandsymptoms Painonpalpitationormovement Swelling,deformity Crepitus Decreasedrangeofmotion Falsemovement(unnaturalmovementofextremity) Decreased/absentsensoryperception Decreased/absentcirculationdistaltoinjury

2.2.7

Assessment
Conductinitialassessmentdetermineifanylifethreateningconditions o Emergencycareforlifethreateningconditionsfirst(severebleeding) Neveroverlookmusculoskeletaltrauma Neverallowanoncriticalmusculoskeletalinjurytodistractfromprioritiesofcare

2.2.8

SIXPsofmusculoskeletalinjuries
Pain Painonpalpation(tenderness) Painonmovement Pale,coldandclammyskin+poorcapillaryrefill Pinsandneedlessensation Diminished/absent Inabilitytomove Compartmentsyndrome(pressurebuildupunderneaththeskin)

Pallor Paraesthesia Pulse Paralysis Pressure

Evaluatinganextremitiesneurovascularstatusby: o Assessingdistalpulse o Function o Sensation(beforeandaftermovement/splinting) Compareinjuredextremitywithoppositeuninjuredextremity Ifextremitytraumasuspectedimmobilizedinjurybysplinting

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MusculoskeletalSystem

Principlesofsplinting
Thegoalofsplintingisimmobilizationoftheinjuredbodypart Immobilizationbysplinting: o Helpsalleviatepain(decreaselevelofpain) o Decreasedtissueinjury Bleedingandcontaminationinopenwound o Simplifiesandfacilitatespt.transport Splintjointsabove+belowandboneends o Immobilizeopenandclosefracturesinsamemanner o Coverfracturestoreducecontamination o Assessandreassess(aftersplinting) distalpulse capillaryrefill neurologicalsensation motorfunctionbeforeandaftersplinting o Stabilizeextremitygently Inlinetractiontonormalpositionofalignment GeneralrulealignONLYONCE o Immobilizelongboneextremityinstraightpositionthatcanbeeasilysplinted Immobilizeddislocationinpositionofcomfort o Ensuregoodvascularsupply Immobilizejointsfound o JointinjuriesonlyalignedifNOdistalpulse Applyicetoreduceswellingandpain Applycompressiontoreduceswelling Elevateextremity(ifpossible)

3.1

Splints
Threemaintypes o Rigidsplints o Softorformablesplints o Tractionsplints

3.1.1

Rigidsplints
Padbeforeuse Canonlychangeitsshapeminimally(andonlywithsomesplints) Bodyneedstobepositionedtofitthesplint o Boardsplints o Cardboardsplints o Samsplint

3.1.2

Softorformablesplints
Canbemouldedintovariousshapestoaccommodatetheinjuredbodypart o Pillows o Blankets o Slingsandswathes

3.1.3

Tractionsplints
Speciallydesignedformidshaftfemurfracture DONOTapplyormaintainsufficienttractiontoreduceafemoralfracture DOESprovideenoughtractiontostabilizeandalignit

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Module9 3.2

MusculoskeletalSystem

Shoulderinjuries
Commoninolderadultsbecauseofweakerbonestructure o Frequentlyresultfromfallonoutstretchedarm

3.2.1

Anteriorfractureanddislocation
Pt.oftenpositionedwithaffectedarmorshoulderclosetochest Lateralaspectofshoulderappearsflatinsteadofround Deepdepressionbetweenheadofhumerusandtheacromionlaterally(hollowshoulder)

3.2.2

Posteriorfractureanddislocation
Pt.maybepositionedwitharmabovehead

3.2.3

Managementofshoulderinjuries(fractureanddislocation)
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applicationofice Applicationofslingandswathe Splintmayneedtobeimprovisedtoholdinjury

3.3

Humerusinjuries
Commoninolderadultsandchildren o Oftendifficulttostabilize

3.3.1

Associatedcomplication
Radialnervedamage o Maybepresentifmiddleordistalportionofhumeralshaftfractured Axillarynervedamage o Maybepresentifhumeralneckfracture Internalhaemorrhaging o IntothejointCompartmentsyndrome(pressurebuildupunderneaththeskin)

3.3.2

ManagementofHumerusinjuries
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applyice Alignifthereisvascularcompromise Applicationofrigidsplitandslingandswathe ORsplinttheextremitywitharmextended

3.4

Radius,Ulna/Wristinjuries
Commoninadultandinchildren Usuallyresultfromfallonoutstretchedarm Wristinjuriesmayinvolve: o Distalradius o Ulna o Oranyoftheeightcarpalbones Commoninjury:CollesFracture(wristfracture)

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Module9 3.4.1

MusculoskeletalSystem

ManagementofHumerusinjuries
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applyice Splintinpositionfountwithrigidorformablesplints/slingandswathe Elevation

3.5

Hand(metacarpal)injuries
Frequentlyresultsfrom: o Contactsports o Violence(fighting) o Crushinginindustrialcontext Commoninjury o Boxersfracture o Resultfromdirecttraumatoclosedfistfracturingfifthmetacarpalbone Injuriesmaybeassociatedwithhaematomasandopenwounds

3.5.1

ManagementofHumerusinjuries
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applyice Splintinpositioninnormalpositionofalignment/normalpositionoffunction Elevation

3.6

Lowerextremityinjuries
Comparetoupperextremityinjurieslowerextremityinjuriesare: o Associatedwithgreaterwoundingforce o Moresignificantbloodloss o Moredifficulttomanageinpt.withmultipleinjuries o Maybelifethreatening: Femurfracture Pelvicfracture Cancausehypovolemicshock

3.6.1

Femurfracture
Usuallyresultfrommajortrauma(MVA/pedestrianaccidents) Fairlycommoninchildabuse Fracturesusuallyevidentfrompowerfulthighmusclesproducingoverridingofbonefragments Pt.generallyhasshortenedleg+externallyrotatedandmidthighswellingfromhaemorrhaging Bleedingmaybelifethreatening

3.6.1.1 ManagementofFemurfracture
Highconcentrationoxygenadministration Treatmentforshock Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill

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Module9

MusculoskeletalSystem

Applicationoftractionsplintmidshaftfemurfracture Regularmonitoringofvitalsigns Rapidtransportisessential

3.6.2

Pelvicfracture
Bluntforcetraumaorpenetratinginjurytopelvismayresultin: o Fracture o Severehaemorrhaging o Associatedinjurytourinarybladderandurethra Deformitymaybedifficulttosee Suspectinjurytopelvisbasedon: o MOI(Mechanismofinjury) o Presenceoftendernessonpalpationoftheiliaccrest(hipbone)

3.6.2.1 ManagementofPelvicfracture
Highconcentrationoxygenadministration Treatmentforshock Fullbodyimmobilization(longspinboardandspiderstraps) o Adequatelypaddedforcomfort Regularmonitoringofvitalsigns Rapidtransportisessential

3.6.3

Hipinjury
Commoninolderadultsbecauseofafall o Alsoinyoungeradultfromtrauma Ifhipfracturedatfemoralheadandneck o Affectedlegusuallyshorterandexternallyrotated(rotatesoutwards) Dislocationofhipusuallyevidencedbyshortenedandrotatedleg

3.6.3.1 ManagementofHipinjury
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Fullbodyimmobilization(longspinboardandspiderstraps) o Adequatelypaddedforcomfort Slightflexofthekneeorpaddingbeneaththekneemayimprovecomfort Regularmonitoringofvitalsigns Rapidtransportisessential

3.7

Kneeandpatellainjuries
Fracturestokneeanddislocationsofpatellacommonlyresultfrom: o MVA o Pedestrianaccidents o Contactsports o Fallsonflexedknee Relationshipofpoplitealarterytokneejointmayleadtovascularinjury o Particularlywithposteriordislocation

3.8

TibiaandFibiainjuries
Mayresultfromdirectorindirecttraumaortwistinginjury Isassociatedwithknee,poplitealvascularinjuryshouldbesuspected

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Module9 3.8.1

MusculoskeletalSystem

Managementoftibiaandfibiainjuries
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applicationofice Splintwithrigidorformablesplint Elevate

3.9

Footandankleinjuries
Fracturesanddislocationoffootandanklemayresultfrom: o Crushinjury o Fallfromheight o Violentrotaryforce Pt.usuallycomplainsofpointtendernessandishesitanttobearweightonextremity

3.9.1

Managementoffootandankleinjuries
Assessandreassess(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill Applicationofice Splintwithrigidorformablesplint(e.g.pillow,blanket/airsplint) Elevate

3.10 OpenFractures
Consideranysofttissuewoundaroundsuspectedfracturetobeevidenceofopenfracture Fracturesmaybeopenintwoways: o Fromwithin(bonefragmentspiercethroughskin) o Fromwithout(gunshot) Openfracturesmayhavemadecontactwithskinsomedistanceawayfromfracture Openfracturesconsideredatruesurgicalemergencybecauseofthepotentialforinfection

3.11 Limbthreateninginjuries
Kneedislocation Fractureordislocationofpoplitealandankle Subcondylarfractureofelbow o Theseinjuryrequirerapidtransportforphysicianevaluation

3.12 Managementoffracturesanddislocations
Elbowshowneverbemanipulatedinprehospitalsetting Asarule,fractureanddislocationshouldbeimmobilizedinpositionofinjury o Andpt.transportedtoemergencydepartmentdoerealignment(reduction) Iftransportdelayed/prolongedandcirculationisimpaired ONEattempttorepositionagrosslydeformedfractured/dislocatedjointshouldbemade

3.12.1 Method
Handleinjurycarefully Applygentle,firmtractionindirectionoflongaxisofextremity Ifnotobviousresistancesplintextremitywithoutrepositioning

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Module9 3.12.2 Realignment


MusculoskeletalSystem

ONLYONEattemptatrealignmentshouldbemadeinprehospitalsetting ONLYifseverneurovascularcompromise(extremelyweak/absentdistalpulse) Manipulationshouldbeperformedassoonaspossible(ONLYifindicated) Shouldbeavoidedinpresenceofotherseverinjuries IfNOcontractindicationsconsideruseofEntonoxforrealignmentprocedure Assess+documentandreassess+document(aftersplinting) o Neurovascularstatus o Neurologicalsensation o Distalpulse o Capillaryrefill

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