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 exam findings would lead you to believe that  What exam findings would lead you to believe that perfusion to the extremity is poor? perfusion to the extremity is poor?  Describe actions that should be taken immediately to  Describe actions that should be taken immediately to improve blood flow to the foot. improve blood flow to the foot.  How will you determine if your actions are successful?  How will you determine if your actions are successful?  What anatomical structures are likely involved in this  What anatomical structures are likely involved in 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 (e.g., urinary bladder and uterus)  Walls of tubes (e.g., respiratory, digestive, reproductive, urinary, and circulatory systems)  Innervated by autonomic nervous system
– Regulates size of lumen of tubular structures

 Contractions strong and slow

Cardiac Muscles
 Have strength of skeletal muscle and endurance of smooth muscle  Provide for movement of blood through the body on a continuous basis
 Respond to stimulation from the nervous system  Highly sensitive to lack of oxygen  Respond to lack of oxygen with pain in that area (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
– – – Sprain Subluxation Dislocation

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

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
– Pain on palpation or movement – Swelling, deformity – Crepitus – Decreased range of motion – False movement (unnatural movement of extremity) – Decreased or absent sensory perception or circulation distal to injury

Six "P"s of Compartment Syndrome
1. Pain
– – On On palpation (tenderness) 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  Instability  Loss of tissue  Simple laceration and contamination  Interruption of blood supply  Nerve damage  Long-term disability

Blood Loss Concerns
 Pelvis
– Per BTLS: 2 units (1 litter) to loss of complete blood volume (5 liters) or 500 ml per fracture

 Rib
– Pneumothorax (can bleed up to 3 liters per pleural cavity)

 Femur
– Per BTLS: 2 units (1 liter) per fracture

 Be prepared to treat hemorrhagic shock

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-/limbthreatening musculoskeletal trauma

– Other life-/limb-threatening injuries and simple musculoskeletal trauma – Life-/limb-threatening musculoskeletal trauma
 No other life-/limbthreatening injuries

– Isolated, non-life-/limbthreatening injuries

Musculoskeletal Injury Assessment
 Scene Size-up  Initial Assessment – Categories of urgency  Life & 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

 Rapid Trauma Assessment  Focused H&P
– 6 P’s: Pain, Pallor, Paralysis, Paresthesia, Pressure, Pulses

 Detailed Physical Exam  Ongoing Assessment  Sports Injury Consideration

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 – Ankle – Foot – Shoulder – Elbow – Wrist/Hand – Finger

Joint Injuries
Alert for PMS Compromis e

Knee Dislocation/Fracture with No Distal Pulse
 Gentle, steady traction while moving extremity into normal alignment  Successful realignment = “Pop,” loss of deformity, relief of pain, increased mobility  Provide full immobilization

 Should be attempted if transport will be greater than 2 hours (even with a pulse)  Patellar dislocation – Not limb threatening

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
 Nitrous Oxide
– – – 50% O2:50% N Non-explosive Effects dissipate in 2-5 minutes – Easily diffused into air filled spaces in body. – Dose
 Inhaled & self administered

Not A Biotel Option  Diazepam
– – – – Benzodiazepine Antianxiety Analgesic Dose
 5-15 mg titrated

– Onset
 10-15 minutes

– Duration
 15-60 minutes

– Onset
 1-2 minutes

– Counter Agent
 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 Analgesic/Anesthetic  Route: Inhalation Adult Dose: Instruct patient to inhale deeply through patient-held mask or mouthpiece Pediatric
 Dose: Instruct patient to inhale deeply through patient-held mask or mouthpiece Drug  Action: Depresses the central nervous system 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 selfadminister Decompression sickness

Morphine Sulfate
 Indications Pain and anxiety secondary to AMI Chest pain unrelieved by Nitroglycerin Pulmonary edema Pain secondary to amputations or fractures
Precautions: Monitor respiratory status and blood pressure closely. Notify Biotel prior to administration if patient is >65yrs of age, debilitated, has altered mental status, or systolic BP<110mmHg CHF: be prepared to intubate Antidote: Naloxone (Narcan®)

Morphine Sulfate
 Class: Narcotic Analgesic 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  Decreases cardiac Pediatric: 0.1mg/kg workload and oxygen demand on the heart

Drug Action:

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