Slide 1

Emergency Care

CHAPTER

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

THIRTEENTH EDITION

Musculoskeletal Trauma

28

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Multimedia Directory

Slide 55 Splinting – Immobilization of a Long Bone

Fracture Video

Slide 86 Hip Fractures Animation

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Topics

• Musculoskeletal System

• General Guidelines for Emergency Care

• Emergency Care of Specific Injuries

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Musculoskeletal System

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Musculoskeletal System

• Bones

 Framework

• Joints

 Bending

• Muscles

 Movement

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Musculoskeletal System

• Cartilage

 Flexibility

• Ligaments

 Connect bone to bone

• Tendons

 Connect muscle to bone

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Anatomy of Bone

• Bones

 Formed of dense connective tissues

 Vascular and susceptible to bleeding on

injury

 Covered by periosteum

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Anatomy of Bone

• Classification of shape

 Irregular

 Long

 Short

 Flat

Bones are classified by shape.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Self-Healing Nature of Bone

• Break causes soft tissue swelling and a

blood clot in the fracture area.

• Interruption of blood supply causes

cells to die at injury site.

• Cells further from fracture rapidly

divide forming tissue that heals the

fracture and develops into new bone.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Muscles

• Kinds of muscles

 Skeletal (voluntary)

 Smooth (involuntary)

 Cardiac (myocardial)

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Cartilage

Cartilage helps form flexible structures of

the body.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Ligaments

Tendons tie muscle to bone. Ligaments tie bone to bone.

Ligaments support joints by attaching bone

ends to allow for stable range of motion

BLB = bone-ligament-bone

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Tendons

Tendons tie muscle to bone. Ligaments tie bone to bone.

Tendons allow for the power of movement

across joints.

MTB = muscle-tendon-bone

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

General Guidelines for

Emergency Care

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Mechanisms of

Musculoskeletal Injury

• Direct force

• Indirect force

• Twisting (rotational) force

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Injury to Bones and

Connective Tissue

• Fracture

 Any break in a bone, open or closed

 Comminuted

• Broken in several places

 Greenstick

• Incomplete break

 Angulated

• Bent at angle

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Injury to Bones and

Connective Tissue

Closed fracture. © Edward T. Dickinson, MD

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Injury to Bones and

Connective Tissue

• Dislocation

 "Coming apart" of a joint

• Sprain

 Stretching and tearing of ligaments

• Strain

 Overstretching or overexertion of

muscle

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Injury to Bones and

Connective Tissue

• Not all injuries can be confirmed as a

fracture in the field.

• Splinting an extremity with a suspected

fracture helps prevent blood loss from

bone tissues.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Assessment of

Musculoskeletal Injuries

• Rapidly identify and treat life-

threatening conditions.

• Be alert for injuries besides grotesque

wound.

• Cut or remove patient's clothing to

complete examination according to the

environment and severity of situation.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Compartment Syndrome

• Severe swelling in the extremity as a

result of fracture

• Progression

 Fracture or crush injury causes bleeding

and swelling in extremity.

 Pressure and swelling become so great

the body can no longer perfuse the

tissues against pressure.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Compartment Syndrome

• Progression

 Cellular damage occurs, causing

additional swelling.

 Blood flow to the area is lost.

• Limb may also be lost if the pressure is

not relieved.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Patient Assessment

• Pain and tenderness

• Deformity and angulation

• Grating (crepitus)

• Swelling and bruising

• Exposed bone ends

• Joints locked into position

• Nerve/blood vessel compromise

• Compartment syndrome

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Patient Assessment

• Six P's of assessment

 Pain or tenderness

 Pallor (pale skin)

 Parasthesia (pins and needles)

 Pulses diminished or absent

 Paralysis

 Pressure

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Think About It

• Do my patient's musculoskeletal

injuries add up to serious multiple

trauma?

• Does my patient have circulation,

sensation, and motor function distal to

the suspected fracture or dislocation?

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Patient Care

• Take Standard Precautions.

• Perform primary assessment.

• During secondary assessment, apply

cervical collar if you suspect spine

injury.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Patient Care

• Splint any suspected extremity

fractures after treating life-threatening

conditions.

• Cover open wounds with sterile

dressings.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Splinting

• Advantages

 Minimizes movement of disrupted joints

and broken bone ends

 Prevents additional injury to soft tissues

• Nerves, arteries, veins, muscles

 Decreases pain

 Minimizes blood loss

 Can prevent a closed fracture from

becoming an open fracture

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Realignment of the

Deformed Extremity

• Assists in restoring effective circulation to

extremity and to fit it to splint

• If not realigned, splint may

be ineffective, causing

increased pain and possible

further injury.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Realignment of the

Deformed Extremity

• If not realigned, increased chance of

nerves, arteries, and veins being

compromised

• Increased pain is only momentary.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Realignment of the

Deformed Extremity

• Guidelines

 One EMT grasps distal extremity while

partner place one hand above and

below injury site.

 Partner supports first EMT who creates

gentle manual traction in direction of

long axis of extremity.

 If no resistance is felt, maintain gentle

traction until extremity is properly

aligned and splinted.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Strategies for Splinting

Splints and accessories for musculoskeletal injuries.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Strategies for Splinting

• Effective splinting may require some

ingenuity.

• Three types available on EMS units

 Rigid splints

 Formable splints

 Traction splints

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Strategies for Splinting

• Care for life-threatening problems first.

• Expose injury site.

• Assess distal CSM.

• Align long-bone injuries to anatomical

position.

• Do not push protruding bones back into

place.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Strategies for Splinting

• Immobilize both injury site and

adjacent joints.

• Choose splinting method based on

severity of condition and priority

decision.

• Apply splint before moving patient to

stretcher or other location if possible.

• Pad voids.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Hazards of Splinting

• "Splinting patient to death"

 Splinting before life-threatening

conditions addressed

• Not ensuring ABC's

• Too tight

 Compresses soft tissues

• Too loose

 Allows too much movement

• Splinting in deformed position

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Treatment: Splinting Long-Bone

and Joints

First Take Standard Precautions.

1. Manually stabilize the injured limb, in this case an injured elbow.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Splinting Long-Bone

and Joint Injuries

• Take appropriate Standard precautions.

• If possible, expose area to be splinted.

• Manually stabilize injury site.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Splinting Long-Bone

and Joint Injuries

• Assess circulation, sensation, and

motor function.

• Realign injury if deformed or if distal

extremity is cyanotic or pulseless.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Treatment: Splinting Long-Bone

and Joints

2. Assess distal pulse, motor function, and sensation (CSM).

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Splinting Long-Bone

and Joint Injuries

• Measure or adjust splint.

 Move it into position.

• Apply and secure splint to immobilize

injury site, adjacent joints.

• Reassess CSM distal to injury.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Treatment: Splinting Long-Bone

and Joints

4. Secure the splint.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Treatment: Splinting Long-Bone

and Joints

5. Reassess distal CSM.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Traction Splint

• Counteracts muscle spasms and greatly

reduces pain

• Types

 Bipolar

 Unipolar

• Amount of traction applied should be

roughly 10 percent of patient's body

weight

 Not exceeding 15 pounds

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Traction Splint

• Take Standard Precautions and, if

possible, expose the area to be

splinted.

• Manually stabilize the leg and apply

manual traction.

• Assess CSM distal to the injury.

• Adjust the splint to the proper length,

and position it at or under the injured

leg.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Traction Splint

• Apply the proximal securing device

(ischial strap).

• Apply the distal securing device (ankle

hitch).

• Apply mechanical traction.

• Position and secure support straps.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Traction Splint

• Reevaluate the proximal and distal

securing devices, and reassess CSM

distal to the injury.

• Secure the patient's torso and the

traction splint to a long spine board to

immobilize the hip and to prevent

movement of the splint.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Treatment: Traction Splint

1. Take Standard Precautions. NOTE: Assess the distal circulation, sensation, and

motor function both before and after immobilizing or splinting an extremity.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Treatment: Traction Splint

2. Manually stabilize the injured leg.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Treatment: Traction Splint

4. Adjust the splint to the proper length, and position it next to the injured leg.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Treatment: Traction Splint

8. Secure support straps, as appropriate.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Splinting – Immobilization of a

Long Bone Fracture Video

Click on the screenshot to view a video on the subject of splinting a long bone injury.

Back to Directory

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Emergency Care of Specific

Injuries

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Shoulder Girdle Injuries

• Patient assessment

 Pain in shoulder

 Dropped shoulder

 Severe blow to back over scapula

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Shoulder Girdle Injuries

• Patient care

 Assess distal CSM.

 Use sling and swathe.

 If evidence of anterior dislocation of

head of humerus, place pillow between

patient's arm and chest.

 Do not attempt to straighten or reduce.

 Reassess distal CSM.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Pelvic Injuries

• Patient assessment

 Pain in pelvis, hips, groin, or back

 Pain when pressure applied to iliac

crests

 Cannot lift legs when lying on back

 Lateral rotation of foot

 Unexplained pressure in bladder

 Bleeding from urethra, rectum, or

vaginal opening

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Pelvic Injuries

• Patient care

 Move patient as little as possible.

 Determine CSM distal to injury site.

 Straighten lower limbs to anatomical

position.

 Stabilize lower limbs.

 Assume spinal injuries.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Pelvic Injuries

• Patient care

 Reassess distal CSM.

 Care for shock, provide high-

concentration oxygen.

 Transport patient as soon as possible.

 Monitor vital signs.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Pelvic Wrap

• Commercially available devices

 Can also use a sheet

• Applied to patients who have pelvic

deformity or instability whether or not

signs of shock are present

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Pelvic Wrap

A commercial pelvic splint.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Pelvic Wrap

To devise a pelvic wrap, lay a sheet, folded flat, approximately 10 inches wide onto

the backboard.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Pelvic Wrap

Bring the sides of the sheet together.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Pelvic Wrap

Tie the sheet firmly without overcompression to complete the pelvic wrap.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Hip Dislocation

• Patient assessment

 Anterior hip dislocation

 Posterior hip dislocation

• Rotation of leg inward and knee is bent.

• Foot may hang loose and unable to flex

the foot or lift toes.

• Lack of sensation in limb

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Hip Dislocation

• Patient care

 Assess distal CSM.

 Move patient onto long spine board.

 Immobilize limb with pillows and

blankets.

 Secure patient to spine board.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Hip Dislocation

• Patient care

 Reassess distal CSM.

 Care for shock.

 Transport, monitor vital signs, check for

nerve and circulation impairment.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Geriatric Note

• Direct force and twisting forces can

cause a hip fracture.

 MVC or falls

• Older adults are more susceptible to

this type of injury because of their

brittle bones or weakness from various

diseases.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Hip Fracture

• Patient assessment

 Pain is localized.

 Surround tissues are discolored.

 Swelling may be evident.

 Unable to move limb while on back

 Unable to stand

 Foot on injured side turns outward.

 Injured limb appears shorter.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Hip Fracture

• Patient care

 Place folded blanket between patient's

legs, and bind legs together with wide

straps, or wide cravats.

 Use thin splints to push cravats or

straps under patient at natural voids

and readjust so they will pass across

the chest, the abdomen just below the

belt, below the crotch, above and below

the knee, and at the ankle.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Hip Injuries

For a patient with a hip injury, bind the legs together.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Femoral Shaft Fracture

• Patient assessment

 Intense pain

 Possibly open fracture

 Injured limb may be shortened

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Femoral Shaft Fracture

• Patient care

 Control bleeding.

 Manage for shock.

 Provide oxygen.

 Assess distal CSM.

 Apply traction splint.

 Reassess distal CSM.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Pediatric Note

• When traction-splinting thigh injuries in

children, be sure to use appropriately-

sized splints.

• Infants and children with fractured

femurs often have injuries to internal

organs.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Knee Injury

• Patient assessment

 Pain and tenderness

 Swelling

 Deformity with swelling

• Patient care

 Assess distal CSM.

 Immobilize in current position.

 Reassess distal CSM.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Tibia or Fibula Injury

• Patient assessment

 Pain and tenderness

 Swelling

 Possible deformity

• Patient care

 Apply air-inflated splint.

 Immobilize fracture using two rigid

board splits.

 Apply single splint with ankle hitch.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Ankle or Foot Injury

• Patient assessment

 Pain

 Swelling

 Possible deformity

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Ankle or Foot Injury

• Patient care

 Assess distal CSM.

 Stabilize limb.

 Lift limb.

 Place cravats under ankle.

 Lower limb into pillow.

 Tie pillow around ankle.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Ankle/Foot Injury

A pillow splint may be used for an injured ankle.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Ankle or Foot Injury

• Patient care

 Tie fourth cravat at arch of foot.

 Elevate with second pillow or blanket.

 Reassess distal CSM.

 Care for shock if needed.

 Apply ice pack as needed.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Forearm, Wrist, and Hand Injuries

• Signs

 Forearm

• Deformity and tenderness

 Wrist

• Deformity and tenderness

 Hand

• Deformity and pain

• Dislocated fingers

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Splinting Forearm, Wrist,

and Hand Injuries

SPLINTING A FINGER: An injured finger can be taped to an adjacent uninjured finger,

which acts as a splint to the injured finger. Or an injured finger can be splinted with a

tongue depressor. Some emergency department physicians prefer that care to an

injured finger be limited to a wrap of soft bandages. Do not try to "pop" dislocated

fingers back into place.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Splinting Forearm, Wrist,

and Hand Injuries

SPLINTING A FINGER: An injured finger can be taped to an adjacent uninjured finger,

which acts as a splint to the injured finger. Or an injured finger can be splinted with a

tongue depressor. Some emergency department physicians prefer that care to an

injured finger be limited to a wrap of soft bandages. Do not try to "pop" dislocated

fingers back into place.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Hip Fractures Animation

Click on the screenshot to view an animation on the subject of hip fractures.

Back to Directory

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Chapter Review

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Chapter Review

• Bones bleed. Fractures cause blood loss

within the bone as well as from tissue

damage around the bone ends. Serious

or multiple fractures can cause shock.

• Splinting of long-bone fractures

involves immobilizing the bone ends as

well as the adjacent joints.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Chapter Review

• Splinting protects the patient from

further injury, reduces pain, and helps

control bleeding.

• You may need to be creative while

splinting. There are many correct ways

to splint the same extremity.

• Injuries to bones and joints should be

splinted prior to moving the patient.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Chapter Review

• If patient has multiple trauma or

appears to have shock (or a significant

potential for shock), do not waste time

splinting individual fractures. Place

patient on long spine board and secure

limbs to board. Splint individual

fractures en route if time and priorities

allow.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Remember

• Bones, joints, muscles, cartilage,

tendons, and ligaments make up the

musculoskeletal system.

• Bones provide the body with structure,

store metabolic materials, and produce

red blood. Joints are the places where

bones articulate to create movement.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Remember

• Fractures, dislocations, sprains, and

strains are musculoskeletal injuries that

are caused by direct force, indirect

force, and twisting force. Injuries

should be splinted prior to moving the

patient.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Remember

• A closed extremity injury is one in

which the skin has not been broken. An

open extremity injury is one in which

the skin has been broken.

• Pelvic fractures and femoral shaft

fractures often indicate more severe

internal injuries.

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Remember

• EMTs must learn specific techniques for

immobilizing particular injuries but at

the same time must foster creativity

while applying the general rules of

splinting.

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Questions to Consider

• Have I fully addressed life threats and

maintained my priorities even in the

presence of a grossly deformed

extremity?

• Does the patient have an injury that

requires splinting?

continued on next slide

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Questions to Consider

• Does the patient have multiple

fractures, multiple trauma, or shock?

• Does the patient have adequate CSM

distal to the musculoskeletal injury?

• Should I align the angulated extremity

fracture?

Emergency Care, 13e

Daniel Limmer | Michael F. O'Keefe

Critical Thinking

• Patients who suffer fractures can be in

extreme pain. Pain can cause anxiety

and elevated pulse rates. How could

you differentiate between a patient with

a rapid pulse and anxiety from pain

versus a patient with rapid pulse and

anxiety from shock?