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Musculoskeletal Musculoskeletal TraumaTrauma
SSgt Jeffery C. PintlerWashington Air National
Guard1
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
2
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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Musculoskeletal System Musculoskeletal System FunctionFunction
Scaffolding/SupportProtection of vital organsMovementProduction of Red Blood CellsStorage of minerals
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Musculoskeletal Musculoskeletal StructuresStructures
SkinMusclesBonesTendonsLigamentsCartilage
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Muscular SystemMuscular System
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Skeletal SystemSkeletal System
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Musculoskeletal Musculoskeletal Structures - Structures - SkinSkin Holds all structures together
Barrier function Protects underlying structures Subcutaneous tissue
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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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SprainsSprains
Stretching. tearing of ligaments surrounding joint
Occur when joint is twisted beyond normal range of motion
Most common = Ankle
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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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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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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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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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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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Sling and swathes applied Sling and swathes applied to humerus fractureto humerus fracture
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Applying a cravat slingApplying a cravat sling
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Splint applied to a Splint applied to a fractured elbowfractured elbow
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Swathes applied to a Swathes applied to a fractured elbowfractured elbow
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Splint applied to a Splint applied to a fractured forearmfractured forearm
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Sling and swath applied to Sling and swath applied to a fractured forearma fractured forearm
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Splint applied to a Splint applied to a fractured wristfractured wrist
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Improvised jacket slingImprovised jacket sling
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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)
43
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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Military Anti-Shock Military Anti-Shock TrousersTrousersPneumatic Anti-Shock Pneumatic Anti-Shock GarmentGarment
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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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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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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
48
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)
49
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
50
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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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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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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Applying and securing a Applying and securing a field dressingfield dressing
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Applying manual pressureApplying manual pressure
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Pressure points for control Pressure points for control of arterial bleedingof arterial bleeding
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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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Application of a tourniquet Application of a tourniquet to stop bleedingto stop bleeding
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ReferencesReferences
Field Manual 8-230 U.S. Army 2003 Combat Lifesaver Instructor
Manual U.S. Army 2003
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