Chapter 15 Injuries to Muscles and Bones National

Chapter 15: Injuries to Muscles and Bones

National EMS Education Standard Competencies (1 of 3) Trauma Uses simple knowledge to recognize and manage life threats based on assessment findings for an acutely injured patient while awaiting additional emergency medical response.

National EMS Education Standard Competencies (2 of 3) Orthopedic Trauma Recognition and management of • Open fractures • Closed fractures • Dislocations • Amputations

National EMS Education Standard Competencies (3 of 3) Head, Facial, Neck, and Spine Trauma Recognition and management of • Life threats • Spine trauma

Introduction (1 of 2) • Emergency medical responders (EMRs) will encounter many types of musculoskeletal injuries: – Fractures – Dislocations – Sprains and strains – Head injuries – Spinal cord injuries – Chest injuries

Introduction (2 of 2) • Understanding the basic anatomy and functioning of the musculoskeletal system will you help you treat these injuries. • You must be able to recognize signs and symptoms of various musculoskeletal injuries. • Providing proper care at the scene can prevent additional injury or disability.

Patient Assessment of Injuries to Muscles and Bones (1 of 2) © Jones & Bartlett Learning. Courtesy of MIEMSS.

Patient Assessment of Injuries to Muscles and Bones (2 of 2) • Complete all five parts of the patient assessment sequence. – Follow standard precautions to protect you and the patient from infectious diseases. – Perform a complete primary assessment. – Immediately follow with the secondary assessment. – Perform a thorough SAMPLE medical history. – Continue to reassess the patient.

The Skeletal System (1 of 9) • Consists of 206 bones • Acts as the supporting framework for the body • Functions of the skeletal system: – To support the body – To protect vital structures – To assist in body movement – To manufacture red blood cells

The Skeletal System (2 of 9) • Divided into seven areas: – Head, skull, and face – Spinal column – Shoulder girdle – Upper extremities – Rib cage (thorax) – Pelvis – Lower extremities

© Jones & Bartlett Learning. The Skeletal System (3 of 9)

The Skeletal System (4 of 9) • The bones of the head include the skull and the lower jawbone. – The skull is actually many bones fused together to form a hollow sphere that contains and protects the brain. – The jawbone is a movable bone attached to the skull.

The Skeletal System (5 of 9) • The spine consists of a series of separate bones called vertebrae. – Primary support structure for the entire body – The spine has five sections: • Cervical spine (neck) • Thoracic spine (upper back) • Lumbar spine (lower back) • Sacrum • Coccyx (tailbone)

The Skeletal System (6 of 9) © Jones & Bartlett Learning.

The Skeletal System (7 of 9) • Each shoulder girdle supports an arm. – Consists of the collarbone (clavicle) and the shoulder blade (scapula) • The upper extremities consist of three major bones plus the wrist and hand. – The arm has one bone (humerus). – The forearm has two bones (radius and ulna).

The Skeletal System (8 of 9) • The 12 sets of ribs protect the heart, lungs, liver, and spleen. © Jones & Bartlett Learning. – All of the ribs are attached to the spine. – The sternum is located in the front of the chest.

The Skeletal System (9 of 9) • The pelvis links the body and the lower extremities. • The lower extremities consist of the thigh and the leg. – The thigh bone (femur) is the longest and strongest bone in the body. – The leg consists of the tibia and fibula, plus the ankle and foot.

The Muscular System (1 of 3) • The muscles of the body provide support and movement. – Muscles are attached to bones by tendons and cause movement by alternately contacting and relaxing. – Movement occurs at joints, where two bones come together. – The bones are held together by ligaments.

The Muscular System (2 of 3) • Three types of muscles – Voluntary (skeletal) muscles are attached to bones and can be contracted and relaxed by a person at will. – Involuntary (smooth) muscles are found on the inside of the digestive tract and other internal organs. – Cardiac muscle is found only in the heart.

The Muscular System (3 of 3) © Jones & Bartlett Learning.

Mechanism of Injury (1 of 2) • Musculoskeletal injuries are caused by three types of mechanisms of injury (MOIs): – Direct force © Jones & Bartlett Learning. – Indirect force – Twisting force

Mechanism of Injury (2 of 2) • Use the information provided by the dispatcher and gathered from the scene to identify the possible MOI. • There are many different ways to describe a patient’s injuries. – Use your senses of sight and touch. – Listen to the information the patient gives you. – The most important part of your job is to provide the best assessment and treatment.

Types of Injuries (1 of 4) • Fractures – A fracture is a broken bone. – It most often occurs as a result of a significant force. – In a closed fracture, the bone is broken but there is no break in the skin. – In an open fracture, the bone is broken and the overlying skin is lacerated. – Both result in bleeding at the fracture site.

Types of Injuries (2 of 4) • Dislocations – A dislocation is a disruption that tears the supporting ligaments of the joint. – The bone ends separate completely from each other and can lock in one position. – Any attempt to move a dislocated joint is very painful. – A dislocation can damage nearby nerves and blood vessels.

Types of Injuries (3 of 4) • Sprains and strains – A sprain is a joint injury caused by excessive stretching of the supporting ligaments. – A strain is caused by stretching or tearing of a muscle.

Types of Injuries (4 of 4) • Signs and symptoms of extremity injuries – Pain at the injury site – An open wound – Swelling and discoloration – The patient’s inability or unwillingness to move the extremity – Deformity or angulation – Tenderness at the injury site

Standard Precautions and Musculoskeletal Injuries • Assume that trauma patients have open wounds that pose a threat of infection. – Always wear approved gloves. • When you respond to a motor vehicle crash, wear heavy rescue gloves. • If the patient has active bleeding that may splatter, you should have protection for your eyes, nose, and mouth.

Examination of Musculoskeletal Injuries (1 of 5) • General patient assessment – All the steps in the patient assessment process must be carried out before focusing on any injured limb. – Limb injuries are not life threatening unless there is excessive bleeding. – Stabilize the patient’s ABCs first.

Examination of Musculoskeletal Injuries (2 of 5) • Examination of the injured limb – Inspect the injured limb and compare it to the opposite, uninjured limb. – When you examine the limb, you may find any one of the following: • Open wound • Deformity • Swelling • Bruising

Examination of Musculoskeletal Injuries (3 of 5) • Examination of the injured limb (cont’d) – Tenderness is the best indicator of an underlying fracture, dislocation, or sprain. © Jones & Bartlett Learning. Courtesy of MIEMSS. – Start at the top of each limb and using both hands, squeeze the entire limb in a systematic, firm manner.

Examination of Musculoskeletal Injuries (4 of 5) • Examination of the injured limb (cont’d) – As you conduct the hands-on examination, ask the patient where it hurts most. – The location of greatest pain is probably the injury site. – If the patient shows no sign of injury, ask the patient to move the limb carefully.

Examination of Musculoskeletal Injuries (5 of 5) • Evaluation of circulation, sensation, and movement – Any injury may have associated blood vessel or nerve damage. – Check circulation and sensation after any movement of the limb. – Follow the steps in Skill Drill 15 -1 to check circulation, sensation, and movement.

Treatment of Musculoskeletal Injuries • All limb injuries are treated the same way in the field. – Cover open wounds with dry, sterile dressings. – Apply firm but gentle pressure to control bleeding. – Apply a cold pack to painful, swollen, or deformed extremities. – Splint the injured limb.

General Principles of Splinting (1 of 4) • Advantages of splinting – Prevents the movement of broken bone ends, a dislocated joint, or damaged soft tissues – Helps to control bleeding – Decreases the risk of additional damage – Prevents closed fractures from becoming open fractures during movement or transport

General Principles of Splinting (2 of 4) • Remove clothing from the injured limb to inspect for open wounds, deformity, swelling, bruising, and capillary refill. • Note and record the pulse, capillary refill, sensation, and movement distal to the point of injury. • Cover all open wounds with a dry, sterile dressing before applying the splint.

General Principles of Splinting (3 of 4) • Do not move the patient before splinting, unless there is an immediate danger. • Immobilize the joint above and the joint below the injury site. • Pad all rigid splints. • Support the injury site and minimize movement of the limb until splinting is completed.

General Principles of Splinting (4 of 4) • Splint the limb without moving it unnecessarily. • When in doubt, splint.

Materials Used for Splinting (1 of 5) • Rigid splints – Made from firm material – Applied to the sides, front, or back of an injured extremity – Common types: padded board splints, molded plastic or aluminum splints, padded wire ladder splints, SAM splints, and folded cardboard splints

Materials Used for Splinting (2 of 5) © American Academy of Orthopaedic Surgeons.

Materials Used for Splinting (3 of 5) • Soft splints – The most commonly used soft splints are vacuum splints and inflatable, clear plastic air splints. – Vacuum splints consist of an inner and outer layer of airtight fabric that is shaped to fit around an arm or a leg. • Follow the steps in Skill Drill 15 -2 to apply a vacuum splint – Air splints are constructed of a clear flexible plastic material.

Materials Used for Splinting (4 of 5) © Jones & Bartlett Learning. Courtesy of MIEMSS.

Materials Used for Splinting (5 of 5) • Traction splints – A traction splint holds a lower extremity fracture in alignment by applying a constant, steady pull on the extremity. – Proper application of a traction splint requires two trained emergency medical technicians (EMTs) working together.

Splinting Specific Injury Sites (1 of 14) • Shoulder girdle injuries – Apply a sling made of a triangular bandage and secure it to the patient’s body with swathes. © Jones & Bartlett Learning. Courtesy of MIEMSS.

Splinting Specific Injury Sites (2 of 14) • Shoulder dislocation – Place a pillow or a rolled blanket in the space between the upper arm and the chest wall. – Apply the sling and swathe as for other shoulder injuries. • Elbow injuries – Do not move an injured elbow from the position in which you find it.

Splinting Specific Injury Sites (3 of 14) • Elbow injuries (cont’d) – Wrap the elbow in a pillow, add padding, and secure the pillow. © American Academy of Orthopaedic Surgeons. – Transport the patient in a sitting position with the splinted elbow resting on his or her lap.

Splinting Specific Injury Sites (4 of 14) • Forearm injuries – Several splints can be used • Air splint • Cardboard splint • SAM splint • Rolled newspapers and magazines

Splinting Specific Injury Sites (5 of 14) • Forearm injuries (cont’d) – Follow the steps in Skill Drill 15 -3 to apply a SAM splint. – Follow the steps in Skill Drill 15 -4 to apply a zippered air splint. – Follow the steps in Skill Drill 15 -5 to apply an unzippered air splint.

Splinting Specific Injury Sites (6 of 14) • Hand, wrist, and finger injuries – Use a bulky hand dressing and a short splint. – Place any amputated parts in a sealed plastic bag and send them to the hospital. – Cover all wounds with a dry, sterile dressing. – Place the hand into the position of function. – Place soft roller dressings into the palm. – Apply a splint and secure it with a soft roller bandage.

Splinting Specific Injury Sites (7 of 14) • Pelvic fractures – Treat the patient for shock, but do not raise the legs until the patient is on a backboard. – Feel for tenderness when you use both hands to firmly compress the patient’s pelvis. © Jones & Bartlett Learning.

Splinting Specific Injury Sites (8 of 14) • Hip injuries – Dislocations and fractures are most common. – Both may result from high-energy trauma. – Fractures occur in elderly persons because bone weakens and become more fragile with age. – Immobilize the hip in the position found. – Use several pillows and rolled blankets. – Place the patient on a long backboard.

Splinting Specific Injury Sites (9 of 14) • Thigh injuries – A fractured femur is very unstable. – Place the patient in a comfortable position, treat for shock, and call for additional personnel and equipment. – Traction splints are the most effective way to splint a unilateral fractured femur. – Follow the steps in Skill Drill 15 -6 to apply a Hare traction splint.

Splinting Specific Injury Sites (10 of 14) © Jones & Bartlett Learning. Courtesy of MIEMSS.

Splinting Specific Injury Sites (11 of 14) • Knee injuries – Immobilize an injured knee in the same position that you find it. © Jones & Bartlett Learning. – If the knee is straight, use long, padded board splints or a long-leg air splint.

Splinting Specific Injury Sites (12 of 14) • Knee injuries (cont’d) – If there is significant deformity • Place pillows, blankets, or clothing beneath the knee. • Secure the splint materials to the leg with bandages, swathes, or cravats. • Secure the injured leg to the uninjured leg. • Place the patient on a backboard.

Splinting Specific Injury Sites (13 of 14) • Leg injuries – Fractures of the leg can be splinted with air splints, cardboard splints, and magazines and newspapers. – Follow the steps in Skill Drill 15 -7 to apply an air splint to the leg.

Splinting Specific Injury Sites (14 of 14) • Ankle and foot injuries – Fractures can be splinted with either a pillow or an air splint. – Place the pillow splint around the injured ankle and foot, and tie or pin it in place. – Follow the steps in Skill Drill 15 -8 to apply a pillow splint to the ankle or foot.

Additional Considerations • Practice splinting until you can quickly and competently apply the principles in any situation. • It takes two people to splint most limb injuries adequately. – One person to stabilize and support the extremity – One person to apply the splint

Injuries to the Head (Skull and Brain) (1 of 10) • Head and spinal cord injuries are common causes of death. – Can also lead to irreversible paralysis and permanent brain damage • The human skull has two primary parts: – The cranium – The facial bones

Injuries to the Head (Skull and Brain) (2 of 10) © Jones & Bartlett Learning.

Injuries to the Head (Skull and Brain) (3 of 10) • MOI – Between the skull and the brain, cerebrospinal fluid (CSF) cushions the brain. – A direct force can injure the skull and brain. – An indirect force can also cause injury. © Jones & Bartlett Learning.

Injuries to the Head (Skull and Brain) (4 of 10) • Types of head injuries – In a closed head injury, bleeding and swelling within the skull may increase pressure on the brain, leading to brain damage and death. – An open head injury usually bleeds profusely. – Examine the nose, eyes, and the wound itself to see if any blood or CSF is seeping out. – Brain tissue or bone may be visible.

Injuries to the Head (Skull and Brain) (5 of 10) © Jones & Bartlett Learning.

Injuries to the Head (Skull and Brain) (6 of 10) • Signs and symptoms of head injuries – Confusion – Unusual behavior – Unconsciousness – Nausea or vomiting – Blood from an ear – Decreasing consciousness – Unequal pupils

Injuries to the Head (Skull and Brain) (7 of 10) • Signs and symptoms (cont’d) – Paralysis – Seizures – External head trauma (bleeding, bumps, bruises) • A serious head injury may produce raccoon eyes and Battle’s sign.

Injuries to the Head (Skull and Brain) (8 of 10) © American Academy of Orthopaedic Surgeons.

Injuries to the Head (Skull and Brain) (9 of 10) • Treatment of head injuries – Immobilize the head in a neutral position. – Maintain an open airway with the jaw-thrust maneuver. – Support the patient’s breathing with oxygen. – Monitor circulation; be prepared to perform cardiopulmonary resuscitation (CPR) if necessary.

Injuries to the Head (Skull and Brain) (10 of 10) • Treatment of head injuries (cont’d) – Determine whether blood or CSF is seeping from a wound or from the nose or ears. – Control bleeding from all head wounds with dry, sterile dressings. – Examine and treat other serious injuries. – Arrange for prompt transport.

Injuries of the Face (1 of 4) • Facial injuries commonly result from the following types of injuries: – Motor vehicle crashes in which the patient’s face hits the steering wheel or windshield – Assaults – Falls

Injuries of the Face (2 of 4) • Airway obstruction is the primary danger in severe facial injuries. – If the patient has facial injuries, suspect a spinal injury. • Treatment of facial injuries – Immobilize the head in a neutral position. – Maintain an open airway with the jaw-thrust maneuver.

Injuries of the Face (3 of 4) • Treatment of facial injuries (cont’d) – Support breathing. – Monitor circulation. – Control bleeding by covering any wound with a dry, sterile dressing and applying direct pressure. – Look for and stabilize other serious injuries. – Arrange for prompt transport.

Injuries of the Face (4 of 4) • Treatment of facial injuries (cont’d) © Jones & Bartlett Learning. – If these measures do not keep the airway clear or if you are unable to control severe bleeding, log roll the patient onto the side.

Injuries to the Spine (1 of 8) • MOIs – A displaced vertebra, swelling, or bleeding may put pressure on the spinal cord and damage it. – In severe cases, the spinal cord may be severed. © Jones & Bartlett Learning.

Injuries to the Spine (2 of 8) • MOIs (cont’d) – Injury to the spinal cord high in the neck paralyzes the diaphragm and results in death. – Gunshot wounds to the chest or abdomen may produce spinal cord injury at that level. – Falls, motor vehicle crashes, and stabbings are other common MOIs. – Suspect a spinal injury if the patient has sustained high-energy trauma.

Injuries to the Spine (3 of 8) • Signs and symptoms of spinal cord injury – Laceration, bruise, or other sign of injury to the head, neck, or spine – Tenderness over any point on the spine or neck – Pain in the neck or spine or pain radiating to an extremity – Extremity weakness, numbness, paralysis, or loss of movement

Injuries to the Spine (4 of 8) • Signs and symptoms (cont’d) – Loss of sensation or movement, or tingling/ burning sensation in any part of the body below the neck – Loss of bowel or bladder control • Treatment of spinal injuries – Place the head and neck in a neutral position. – Stabilize the head and prevent movement of the neck.

Injuries to the Spine (5 of 8) • Treatment of spinal injuries (cont’d) – Maintain an open airway with the jaw-thrust maneuver. – Support the patient’s breathing by administering oxygen and by keeping the airway open. – Monitor circulation. – Assess the pulse, movement, and sensation in all extremities.

Injuries to the Spine (6 of 8) • Treatment of spinal injuries (cont’d) – Examine and treat other serious injuries. – Immobilize the patient on a long or short backboard. – Arrange for prompt transport. • Stabilizing the cervical spine – Follow the steps in Skill Drill 15 -9.

Injuries of the Spine (7 of 8) • Motorcycle and sports helmets – Helmets often do not need to be removed. – Remove part or all of a helmet only under the following two circumstances: • When the face mask or visor interferes with adequate ventilation or with your ability to restore an adequate airway • When the helmet is so loose that securing it to the spinal immobilization device will not provide adequate immobilization of the head

Injuries of the Spine (8 of 8) • Motorcycle and football helmets (cont’d) – Follow the steps in Skill Drill 15 -10 to remove the mask on a sports helmet. – Follow the steps in Skill Drill 15 -11 to remove a helmet.

Injuries of the Chest (1 of 7) • Fractures of the ribs – Even a simple fracture produces pain at the site and difficulty breathing. – Rib fractures may be associated with injury to the underlying organs. © Jones & Bartlett Learning.

Injuries of the Chest (2 of 7) • Fractures of the ribs (cont’d) – To determine whether a rib is bruised or broken, apply some pressure to another part of the rib. – Be alert for signs and symptoms of internal injury, particularly shock. – Place a pillow against the injured ribs to splint them.

Injuries of the Chest (3 of 7) • Fractures of the ribs (cont’d) – Prevent excessive movement of the patient. – Administer oxygen if it is available. • Flail chest – If three or more ribs are broken in at least two places, the injured portion of the chest wall does not move with the rest of the chest.

Injuries of the Chest (4 of 7) • Flail chest (cont’d) – A flail chest decreases the amount of oxygen and carbon dioxide exchanged in the lungs. © Jones & Bartlett Learning.

Injuries of the Chest (5 of 7) • Flail chest (cont’d) – Do not restrict movement of the chest if the patient is having difficulty breathing. – It may be helpful to support the patient’s breathing with positive pressure using a bag valve mask and supplemental oxygen. – Monitor and support the patient’s ABCs. – Arrange for prompt transport.

Injuries of the Chest (6 of 7) • Penetrating chest wounds – If an object penetrates the chest wall, air and blood escape into the space between the lungs and the chest wall. – The air and blood may cause the lung to collapse. © Jones & Bartlett Learning.

Injuries of the Chest (7 of 7) • Penetrating chest wounds (cont’d) – Blood loss into the chest cavity can produce shock. – Quickly seal an open chest wound with an occlusive dressing. – Administer oxygen if it is available. – If a knife or other object is impaled in the chest, do not remove it. – Arrange for prompt transport.

Summary (1 of 4) • Musculoskeletal injuries are caused by three types of MOIs: direct force, indirect force, and twisting force. • Fractures can be closed (the bone is broken but there is no break in the skin) or open (the bone is broken and the overlying skin is lacerated).

Summary (2 of 4) • A dislocation is a disruption that tears the supporting ligaments of the joint. • A sprain is a joint injury caused by excessive stretching of the supporting ligaments. • The three basic types of splints are rigid, soft, and traction.

Summary (3 of 4) • In a closed head injury, bleeding and swelling within the skull may increase pressure on the brain, leading to irreversible brain damage. An open injury of the head usually bleeds profusely. • Airway obstruction is the primary danger in severe facial injuries.

Summary (4 of 4) • When you suspect a spinal injury, do not move the patient during the examination. • The most common chest injuries are rib fractures, flail chest, and penetrating wounds.

Review 1. The musculoskeletal system refers to the A. involuntary muscles of the nervous system. B. connective tissue that supports the skeleton. C. bones and voluntary muscles of the body. D. nervous system’s control over the muscles.

Review Answer: C. bones and voluntary muscles of the body.

Review 2. When examining an injured extremity, you should be sure to A. manipulate it in different directions to determine where fractures might exist. B. keep it elevated at all times. C. splint it to reduce movement before conducting any assessments. D. squeeze the entire limb starting from the top in a systematic, firm manner.

Review Answer: D. squeeze the entire limb starting from the top in a systematic, firm manner.

Review 3. Facial injuries should be identified and treated as soon as possible because A. bleeding is more obvious on the face. B. patients are always concerned about their faces. C. swelling may mask hidden injuries. D. of the risk for airway problems.

Review Answer: D. of the risk for airway problems.