Musculoskeletal Injuries
Scenario You respond to a football field for an “accidental injury.” Your patient is a 23-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.
YOUR SCENE
Discussion What What exam exam findings findings would would lead lead you you to to believe believe that that perfusion perfusion to to the the extremity extremity is is poor? poor? Describe Describe actions actions that that should should be be taken taken immediately immediately to to improve improve blood blood flow flow to to the the foot. foot. How How will will you you determine determine ifif your your actions actions are are successful? successful? What What anatomical anatomical structures structures are are likely likely involved involved in in this this injury? injury?
Introduction to Musculoskeletal Injuries Millions of Americans experience annually. Multiple MOI – Falls, Crashes, Violence, etc – Multi-system trauma
Anatomy & Physiology of the Musculoskeletal System Skeletal Tissue & Structure – Protections organs – Allows for efficient movement – Stores salts and other materials needed for metabolism – Produces RBC’s
Pathophysiology of the Musculoskeletal System
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
– Upper limbs (60) – Pelvic girdle (2) – Lower limbs (60)
Anatomy — Skeletal System Bone Classifications 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 Have striations Greater strength Referred to as striated muscle Are under voluntary control Also called voluntary muscles
Skeletal Muscles
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 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)
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 – – –
Sprain Subluxation Dislocation
Bone Injury – – – –
Open Fracture Closed Fracture Hairline Fracture Impacted Fracture
TERMS Subluxation – An incomplete dislocation Luxation – A complete dislocation Crepitus – A grating sound associated with rubbing of bone fragments. Angulated fracture – A broken bone where there is a departure from a straight bone Fracture dislocation – An injury in which the joint is dislocated and a part of the bone near the joint fractures
Pathophysiology — Mechanism of Injury Five forces cause bone and joint injury Direct force Indirect force Twisting force Pathological Fatigue
Classifications of Musculoskeletal Injuries Injuries include: – 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 Some forms of arthritis Malignancy
Pathophysiology — Fractures Unstable — Proximal and distal ends move freely in relationship to each other Open — Skin is open, allowing introduction of bacteria, dirt, and other foreign bodies Closed — Skin is intact
Fracture with dislocation — Fracture at joint with injury to supporting structures Impacted — Jammed together so there is no movement between proximal and distal bones
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
Pathophysiology — Fractures Impacted
Pathophysiology — Fractures
Compartment Syndrome – Muscle enclosed in tough non-stretchable membrane – Pressure builds from bleeding – Applied to blood vessels and nerves – Circulation impossible – Develop over a period of hours (6Ps) – Gangrene (Long Term)
Joint Dislocations Normal articulating ends of two or more bones are displaced
– 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 – 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 – Bursitis – Tendinitis – Arthritis Osteoarthritis – Degenerative
Rheumatoid Arthritis – Chronic, systemic, progressive, debilitating
Gout – Inflammation of joints produced by accumulation of uric acid crystals
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: – 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 – 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 – 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 1. Pain – –
On On
palpation (tenderness) movement
2. Pallor—pale skin or poor capillary refill 3. Paresthesia—pins and needles sensation 4. Pulses—diminished or absent 5. Paralysis—inability to move 6. Pressure
Associated Complications Hemorrhage Instability Loss of tissue Simple laceration and contamination
Interruption of blood supply Nerve damage Long-term disability
Blood Loss Concerns Pelvis – Per BTLS: 2 units (1 litter) to loss of complete blood volume (5 liters) or 500 ml per fracture
Femur – Per BTLS: 2 units (1 liter) per fracture
Rib – Pneumothorax (can bleed up to 3 liters per pleural cavity)
Be prepared to treat hemorrhagic shock
Assessment Determine if life-threatening conditions are present – Care for those first
Never overlook musculoskeletal trauma Don’t allow noncritical musculoskeletal injury to distract from priorities of care
Musculoskeletal Assessment Four classes of patients – Life-/limb-threatening injuries or conditions Includes life-/limbthreatening musculoskeletal trauma
– Other life-/limb-threatening injuries and simple musculoskeletal trauma – Life-/limb-threatening musculoskeletal trauma No other life-/limbthreatening injuries
– Isolated, non-life-/limbthreatening injuries
Musculoskeletal Injury Assessment Scene Size-up Initial Assessment – Categories of urgency 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
Rapid Trauma Assessment Focused H&P – 6 P’s: Pain, Pallor, Paralysis, Paresthesia, Pressure, Pulses
Detailed Physical Exam Ongoing Assessment Sports Injury Consideration
Age-Associated Changes in Bones 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
Knee dislocation Fracture or dislocation of ankle Subcondylar fractures of elbow Require rapid transport
Musculoskeletal Injury Management Other Injury Consideration – Pediatric Musculoskeletal Injury – Athletic Musculoskeletal Injury – Patient Refusals & Referral – Psychological Support
Musculoskeletal Injury Management General Principles – Protecting Open Wounds – Positioning the limb – Immobilizing the injury – Checking Neurovascular Function
Musculoskeletal Injury Management Splinting Devices – – – – –
Rigid splints Formable Splints Soft Splints Traction Splints Other Splinting Aids Vacuum Splints Air Sprints Cravats or Velcro Splints
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 – 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 – Hip – Knee – Ankle – Foot – Shoulder – Elbow – Wrist/Hand – Finger
Joint Injuries Alert for PMS Compromis e
Knee Dislocation/Fracture with No Distal Pulse Gentle, steady traction while moving extremity into normal alignment Successful realignment = “Pop,” loss of deformity, relief of pain, increased mobility Provide full immobilization
Should be attempted if transport will be greater than 2 hours (even with a pulse) Patellar dislocation – Not limb threatening
Dislocation/Fracture Realignment
Never Never manipulate the elbow!
Musculoskeletal Injury Management Soft & Connective Tissue Injuries – Tendon – Ligament – Muscle
Cold vs. Hot Therapy Cold Therapy – Applied for 20 minutes periods – First 24 hour – Reduces pain and swelling
Hot Therapy – After 24 hour – Increases circulation
Musculoskeletal Injury Management Medications Nitrous Oxide – – –
50% O2:50% N Non-explosive Effects dissipate in 2-5 minutes – Easily diffused into air filled spaces in body. – Dose Inhaled & self administered
– Onset 1-2 minutes
Not A Biotel Option Diazepam – – – –
Benzodiazepine Antianxiety Analgesic Dose 5-15 mg titrated
– Onset 10-15 minutes
– Duration 15-60 minutes
– Counter Agent Flumazenil
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 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 selfadminister 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
Drug Action:
Alleviates pain Decreases peripheral Dose: Adult: Administer in vascular resistance titrated doses of 2 - 4mg, vasodilator up to a maximum of 10mg Decreases cardiac Pediatric: 0.1mg/kg workload and oxygen demand on the heart
QUESTIONS?