Musculoskeletal Injuries

Scenario
You respond to a soccer field for an “accidental injury.” Your patient is a 33-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.

Discussion

What exam findings would lead you to believe that perfusion to the extremity is poor? Describe actions that should be taken immediately to improve blood flow to the foot. How will you determine if your actions are successful? What anatomical structures are likely involved in this injury?

Introduction to Musculoskeletal Injuries

Millions of Americans experience annually. Multiple MOI
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Falls, Crashes, Violence, etc Multi-system trauma

Anatomy & Physiology of the Musculoskeletal System

Skeletal Tissue & Structure
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Protections organs Allows for efficient movement Stores salts and other materials needed for metabolism Produces RBC’s

Pathophysiology of the Musculoskeletal System
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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

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Upper limbs (60) Pelvic girdle (2) Lower limbs (60)

Anatomy — Skeletal System
Bone Classifications
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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
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Have striations Greater strength Referred to as striated muscle Are under voluntary control Also called voluntary muscles

Skeletal Muscles
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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
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)

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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
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Sprain Subluxation Dislocation Open Fracture Closed Fracture Hairline Fracture Impacted Fracture

Bone Injury
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Pathophysiology — Mechanism of Injury
Five forces cause bone and joint injury
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Direct force Indirect force Twisting force Pathological Fatigue

Classifications of Musculoskeletal Injuries

Injuries include:
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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
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Some forms of arthritis Malignancy

Pathophysiology — Fractures
Unstable — Proximal and distal ends move freely in relationship to each other Impacted — Jammed together so there is no movement between proximal and distal bones Open — Skin is open, allowing introduction of bacteria, dirt, and other foreign bodies Closed — Skin is intact Fracture with dislocation — Fracture at

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

Classification of Fractures

Oblique Transverse Stress Pathological Epiphyseal

Classification of Fractures

Pathophysiology — Fractures Impacted

Pathophysiology — Fractures

Joint Dislocations

Normal articulating ends of two or more bones are displaced
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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
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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
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Bursitis Tendinitis Arthritis

Osteoarthritis

Degenerative Chronic, systemic, progressive, debilitating Inflammation of joints produced by accumulation of uric acid crystals

Rheumatoid Arthritis

Gout

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:
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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
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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
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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

Pain
 

On palpation (tenderness) On movement

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Pallor—pale skin or poor capillary refill Paresthesia—pins and needles sensation Pulses—diminished or absent Paralysis—inability to move Pressure

Associated Complications

Hemorrhage Instability Loss of tissue Simple laceration and contamination Interruption of blood supply Nerve damage Long-term disability

Assessment

Determine if life-threatening conditions are present

Care for those first

Never overlook musculoskeletal trauma Don’t allow noncritical musculoskeletal injury to distract

Musculoskeletal Assessment

Four classes of patients

Life-/limb-threatening injuries or conditions

Includes life-/limb-threatening musculoskeletal trauma

Other life-/limb-threatening injuries and simple musculoskeletal trauma Life-/limb-threatening musculoskeletal trauma

No other life-/limb-threatening injuries

Isolated, non-life-/limb-threatening

Musculoskeletal Injury Assessment
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Scene Size-up Initial Assessment

Categories of urgency
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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

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Rapid Trauma Assessment Focused H&P

6 P’s: Pain, Pallor, Paralysis, Paresthesia, Pressure, Pulses

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Detailed Physical Exam Ongoing Assessment Sports Injury Consideration

Age-Associated Changes in Bones
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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
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Knee dislocation Fracture or dislocation of ankle Subcondylar fractures of elbow Require rapid transport

Musculoskeletal Injury Management

Other Injury Consideration
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Pediatric Musculoskeletal Injury Athletic Musculoskeletal Injury Patient Refusals & Referral Psychological Support

Musculoskeletal Injury Management

General Principles
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Protecting Open Wounds Positioning the limb Immobilizing the injury Checking Neurovascular Function

Musculoskeletal Injury Management

Splinting Devices
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Rigid splints Formable Splints Soft Splints Traction Splints Other Splinting Aids  Vacuum Splints  Air Sprints  Cravats or Velcro Splints

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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
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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
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Hip Knee Ankle Foot Shoulder Elbow Wrist/Hand Finger

Joint Injuries
Alert for PMS Compromis

Musculoskeletal Injury Management

Soft & Connective Tissue Injuries
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Tendon Ligament Muscle

Musculoskeletal Injury Management Medications

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

Not A Biotel Option  Diazepam
   

Benzodiazepine Antianxiety Analgesic Dose

5-15 mg titrated 10-15 minutes 15-60 minutes Flumazenil

Onset

Duration

Inhaled & self administered 1-2 minutes

Counter Agent

Onset

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
 n n 

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 self-administer 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 Dose: Adult: Administer in titrated doses of 2 4mg, up to a maximum of 10mg Pediatric: 0.1mg/kg

Drug Action: Alleviates pain
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Decreases peripheral vascular resistance vasodilator Decreases cardiac workload and oxygen demand on the heart

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