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Muscle Skeletal

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SSgt Jeffery C. PintlerWashington Air National Guard
61
Musculoskeletal Trauma Musculoskeletal Trauma SSgt Jeffery C. Pintler Washington Air National Guard 1
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Page 1: Muscle Skeletal

Musculoskeletal Musculoskeletal TraumaTrauma

SSgt Jeffery C. PintlerWashington Air National

Guard1

Page 2: Muscle Skeletal

Incidence/Mortality/Incidence/Mortality/MorbidityMorbidity

Occur in 70-80% of all multi-trauma patients

Blunt or Penetrating Upper extremity rarely life-

threatening– may result in long-term impairment

Lower extremity associated with more severe injuries– possibility of significant blood loss– femur, pelvic injuries may pose life-

threat

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Page 3: Muscle Skeletal

Incidence/Mortality/Incidence/Mortality/MorbidityMorbidity

Problem is not just the bone injury– Other injuries caused by the injured

bone» Soft tissue» Vascular» Nervous system» Decreased function

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Page 4: Muscle Skeletal

Musculoskeletal System Musculoskeletal System FunctionFunction

Scaffolding/SupportProtection of vital organsMovementProduction of Red Blood CellsStorage of minerals

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Page 5: Muscle Skeletal

Musculoskeletal Musculoskeletal StructuresStructures

SkinMusclesBonesTendonsLigamentsCartilage

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Page 6: Muscle Skeletal

Muscular SystemMuscular System

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Page 7: Muscle Skeletal

Skeletal SystemSkeletal System

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Page 8: Muscle Skeletal

Musculoskeletal Musculoskeletal Structures - Structures - SkinSkin Holds all structures together

Barrier function Protects underlying structures Subcutaneous tissue

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Page 9: Muscle Skeletal

Musculoskeletal Musculoskeletal Structures -Structures -MuscleMuscle Three types of muscle cells

Voluntary (Skeletal)– Conscious control

Smooth (Bronchi, GI tract, blood vessels)– Unconscious control

Cardiac– Contracts rhythmically on its own

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Page 10: Muscle Skeletal

Musculoskeletal Musculoskeletal StructuresStructures

Tendons– Bands of connective tissue binding

muscles to bones Cartilage

– Connective tissue covering the ends of bones

– Needed for joint movement Ligaments

– Connective tissue supporting joints– Attach bone ends to each other

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Page 11: Muscle Skeletal

Types of JointsTypes of Joints

Ball/Socket–Shoulder/Hip

Hinge–Elbow/Knees/Fingers/TMJ

Pivot–Between radius and ulna

Gliding–Bones of wrist

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Page 12: Muscle Skeletal

FractureFracture

Break in continuity of bone Closed

– Overlying skin intact Open

– Wound extends from body surface to fracture site

– Produced either by bones or object that caused Fx

– Danger of infection– Bone end not necessarily visible

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Page 13: Muscle Skeletal

Common fracturesCommon fractures

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Fracture DescriptionsFracture Descriptions

Open vs Closed X-Ray descriptions

– greenstick– oblique– transverse– comminuted– spiral– impacted– epiphyseal

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Page 15: Muscle Skeletal

Complications associated Complications associated with Fractureswith Fractures

Hemorrhage– Possible loss within first 2 hours

» Tib/Fib - 500 ml» Femur - 500 ml» Pelvis - 2000 ml

Interruption of Blood Supply– Compression on artery

» decreased distal pulse

– Decreased venous return

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Page 16: Muscle Skeletal

Complications associated Complications associated with Fractureswith Fractures

Disability– Diminished sensory or motor function

» inadequate perfusion» direct nerve injury

Specific Injuries– Dislocation– Amputation/Avulsion– Crush Injury (soft tissue trauma

discussion)

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Page 17: Muscle Skeletal

Musculoskeletal Musculoskeletal AssessmentAssessment

Initial Assessment– ABCDs– Life threats managed first– Don’t overlook life/limb threatening

musculoskeletal trauma– Don’t be distracted by “gross” but

non-life/limb threatening musculoskeletal injury

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Page 18: Muscle Skeletal

Musculoskeletal Musculoskeletal AssessmentAssessment

The six “P”s of musculoskeletal assessment– Pain

» on palpation» on movement» constant

– Pallor - pale skin or poor cap refill– Paresthesia - “pins and needles”

sensation– Pulses - diminished or absent– Paralysis– Pressure

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Page 19: Muscle Skeletal

Musculoskeletal Musculoskeletal AssessmentAssessment

Palpation and Inspection– Swelling/Ecchymosis

» Hemorrhage/Fluid at site of trauma

– Deformity/Shortening of limb» Compare to other extremity if norm is

questioned

– Guarding/Disability» Presence of movement does not rule out

fracture

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Page 20: Muscle Skeletal

Musculoskeletal Musculoskeletal AssessmentAssessment

Palpation and Inspection– Tenderness

» Use two point fixation of limb with palpation with other hand.

» Tenderness tends to localize over injury site.

– Crepitus» Grating sensation » Produced by bones rubbing against each

other. » Do not attempt to elicit.

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Page 21: Muscle Skeletal

Musculoskeletal Musculoskeletal AssessmentAssessment

Palpation and Inspection– Distal to injury, assess:

» skin color » skin temperature» sensation» motor function

– If uncertain, compare extremities– When in doubt splint!

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Page 22: Muscle Skeletal

Musculoskeletal Musculoskeletal AssessmentAssessment

Initial Assessment– ABCDs– Life threats managed first– Don’t overlook life/limb threatening

musculoskeletal trauma– Don’t be distracted by “gross” but

non-life/limb threatening musculoskeletal injury

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Page 23: Muscle Skeletal

Management - GeneralManagement - General

Immobilization Objectives– Prevent further damage to

nerves/blood vessels– Decrease bleeding, edema– Avoid creating an open Fracture– Decrease pain– Early immobilization of long bone

fractures critical in preventing fat embolism

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Page 24: Muscle Skeletal

Management - GeneralManagement - General

Principles of Fracture Management– Splint joint above, below– Splint bone ends– Loosely cover open fracture sites– Neurovascular assessment

» before and after splinting

– Gentle in-line traction of long bone » maintain normal alignment if possible» reduction of angulated fracture site

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Page 25: Muscle Skeletal

Management - GeneralManagement - General Principles of Fracture Management

(cont)– Position of function– Pain management

Body Splinting – In urgent patient, entire body is stabilized by

using a long board– Lower extremity fractures can be splinted as

one to the long board Long Board

– Splints every bone and joint– No loss of time– Focus on critical conditions

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Page 26: Muscle Skeletal

DislocationsDislocations

Displacement of bone end from articulating surface at joint

Pain or pressure is most common symptom

Principal sign is deformity May experience loss of motion of

joint

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Page 27: Muscle Skeletal

DislocationsDislocations

Nerves, blood vessels pass very close to bone. Pressure on these structures can occur

Checking distally essential– Pulse presence– Pulse strength– Sensation

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Page 28: Muscle Skeletal

SprainsSprains

Stretching. tearing of ligaments surrounding joint

Occur when joint is twisted beyond normal range of motion

Most common = Ankle

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Page 29: Muscle Skeletal

Sprain ManagementSprain Management

Characteristics– Pain– Tenderness– Swelling– Discoloration

Typically does not manifest deformity Ice, compression, elevation,

immobilize When in doubt, splint Consider analgesia

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Page 30: Muscle Skeletal

StrainsStrains

Tearing, stretching of musculo/tendonous unit.

Spasm, pain on active movement Usually no deformity, swelling Pain present on active movement Avoid active movement, weight

bearing

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Page 31: Muscle Skeletal

Traumatic AmputationTraumatic Amputation

First priority - ABC’s– Bleeding from stump usually not a

problem Next priority is to save limb

Traumatic Amputation ManagementTraumatic Amputation Management

•Control Bleeding•Elevate•Apply direct pressure to stump•Avoid tourniquet except as last resort

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Page 32: Muscle Skeletal

Tourniquet applied to an Tourniquet applied to an arm amputationarm amputation

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Tourniquet applied to a Tourniquet applied to a leg amputationleg amputation

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Page 34: Muscle Skeletal

Traumatic Amputation - Traumatic Amputation - Limb ManagementLimb Management

Place in saline moist gauze Place in plastic bag Place bag on ice Do not

– Warm amputated part– Place part in water– Place directly on ice– Use dry ice

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Page 35: Muscle Skeletal

Sling and swathes applied Sling and swathes applied to humerus fractureto humerus fracture

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Page 36: Muscle Skeletal

Applying a cravat slingApplying a cravat sling

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Page 37: Muscle Skeletal

Splint applied to a Splint applied to a fractured elbowfractured elbow

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Page 38: Muscle Skeletal

Swathes applied to a Swathes applied to a fractured elbowfractured elbow

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Page 39: Muscle Skeletal

Splint applied to a Splint applied to a fractured forearmfractured forearm

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Page 40: Muscle Skeletal

Sling and swath applied to Sling and swath applied to a fractured forearma fractured forearm

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Page 41: Muscle Skeletal

Splint applied to a Splint applied to a fractured wristfractured wrist

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Page 42: Muscle Skeletal

Improvised jacket slingImprovised jacket sling

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Page 43: Muscle Skeletal

Pelvic FracturePelvic Fracture

Direct or indirect force Pelvic ring tends to break in two

places Bone fragments can cause damage

– Major vessels– Urinary bladder– Rectum resulting in contamination– Nerves (Lumbrosacral plexus or sciatic)

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Page 44: Muscle Skeletal

Pelvic Fx ManagementPelvic Fx Management

Treat as potential critical trauma patient

Comfortable position if possible Splint = Minimize movement

– Scoop stretcher– Body to long board– MAST for splint

Replace volume prn– Possible 4000cc blood loss– 2 IV of LR

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Page 45: Muscle Skeletal

Military Anti-Shock Military Anti-Shock TrousersTrousersPneumatic Anti-Shock Pneumatic Anti-Shock GarmentGarment

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Page 46: Muscle Skeletal

Femur FractureFemur Fracture

Femoral Neck (Hip)– Most common in mid to late 60’s age

group.– Leg tends to rotate outward

» looks like anterior hip dislocation

– Minimal blood loss tends to occur due to joint capsule

Management– NO traction splint– long board, scoop or MAST

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Page 47: Muscle Skeletal

Femur FractureFemur Fracture

Mid-Shaft– Result from torsion in very young or

old– High speed deceleration with impact

» Hypovolemic shock» Fat Embolism

– Early immobilization with traction splint will help prevent

– 1000 to 2000 cc blood loss

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Page 48: Muscle Skeletal

Femur Fracture - Femur Fracture - ManagementManagement

Assess for traction splint contraindications

May use PASG, secure to long board– Secure to opposite extremity and then

to long board (premise for the Sager splint)

Assess for :– Soft tissue, vascular, or nerve injury– Assess for hypovolemia

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Page 49: Muscle Skeletal

Femur Fracture - Femur Fracture - ManagementManagement

Traction Splints– Used on mid-shaft femur fractures– Do not use if suspected fracture

involves» proximal or distal 1/3 of femur» pelvis» hip (or hip dislocation)» knee (or knee dislocation)» ankle (or ankle dislocation)

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Page 50: Muscle Skeletal

Lower Extremity FractureLower Extremity Fracture

Patellar– Due to direct impact

Tibia/Fibula– High potential for:

» Open fracture» Hemorrhage» Infection

Calcaneal– Results from falls (foot landing)– High incidence of lumbar sacral

compression

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Page 51: Muscle Skeletal

Management - Lower Management - Lower Extremity FractureExtremity Fracture

Patellar, Tibia/Fibula, and Calcaneal– Assess for neurovascular impairment– Realign long bones– Splinting possibilities

» board splint or cardboard splint» vacuum splint» pillow

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Page 52: Muscle Skeletal

Splint applied to an upper Splint applied to an upper leg fractureleg fracture

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Splint applied to a Splint applied to a fractured kneefractured knee

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Uninjured leg used as a Uninjured leg used as a splintsplint

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Page 55: Muscle Skeletal

Hemorrhage ManagementHemorrhage Management

Direct Pressure– Most effective method– Pressure bandage

Elevation– Combination with direct pressure

Pressure Point– Brachial, Femoral, Carotid

Tourniquet– last resort– rarely required

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Page 56: Muscle Skeletal

Applying and securing a Applying and securing a field dressingfield dressing

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Page 57: Muscle Skeletal

Applying manual pressureApplying manual pressure

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Page 58: Muscle Skeletal

Pressure points for control Pressure points for control of arterial bleedingof arterial bleeding

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Page 59: Muscle Skeletal

TourniquetTourniquet

Last resort, but do not wait too long.

Use flat wide material BP cuff Close to the wound as possible Do not remove Leave in plain view Note time applied and clearly

communicate during transfer of care

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Page 60: Muscle Skeletal

Application of a tourniquet Application of a tourniquet to stop bleedingto stop bleeding

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Page 61: Muscle Skeletal

ReferencesReferences

Field Manual 8-230 U.S. Army 2003 Combat Lifesaver Instructor

Manual U.S. Army 2003

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