29: Musculoskeletal Care

Cognitive Objectives (1 of 2)
5-3.1 Describe the function of the muscular system.
5-3.2 Describe the function of the skeletal system.
5-3.3 List the major bones or bone groupings of the
spinal column, the thorax, the upper extremities,
and the lower extremities.
5-3.4 Differentiate between an open and closed
painful, swollen, deformed extremity (fracture).
 Cognitive Objectives (2 of 2)
5-3.5 State the reasons for splinting.
5-3.6 List the general rules of splinting.
5-3.7 List the complications of splinting.
5-3.8 List the emergency medical care for a patient with
a swollen, painful, deformed extremity (fracture).
 Affective Objectives
5-3.9 Explain the rationale for splinting at the scene
versus load and go.
5-3.10 Explain the rationale for immobilization of the
painful, swollen, deformed extremity (fracture).
 Psychomotor Objectives
5-3.11 Demonstrate the emergency medical care of a
patient with a painful, swollen, deformed extremity
(fracture).
5-3.12 Demonstrate completing a prehospital care
report for patients with musculoskeletal injuries.
 Anatomy and Physiology
of the Musculoskeletal System
Skeletal System
 Types of Musculoskeletal Injuries
• Fracture
– Broken bone
• Dislocation
– Disruption of a joint
• Sprain
– Joint injury with
tearing of ligaments
• Strain
– Stretching or tearing
of a muscle
 Mechanism of Injury
• Force may be applied in several ways:

Direct blow High-energy

Twisting force
Indirect force injury
 Fractures
• Closed fracture
– A fracture that does not break the skin
• Open fracture
– External wound associated with fracture
• Nondisplaced fracture
– Simple crack of the bone
• Displaced fracture
• Fracture in which there is actual deformity
Kickboxing Leg Break
Greenstick Fracture
Comminuted Fracture
Pathologic Fracture
Epiphyseal Fracture
 Signs and Symptoms
of a Fracture (1 of 2)
• Deformity
• Tenderness
• Guarding
• Swelling
• Bruising
 Signs and Symptoms
of a Fracture (2 of 2)
• Crepitus
• False motion
• Exposed fragments
• Pain
• Locked joint
 Signs and Symptoms
of a Dislocation
• Marked deformity
• Swelling
• Pain
• Tenderness on palpation
• Virtually complete loss of joint function
• Numbness or impaired circulation to the limb
and digit
Signs and Symptoms of a Sprain
• Point tenderness can be elicited over
injured ligaments.
• Swelling and ecchymosis appear at the
point of injury to the ligaments.
• Pain
• Instability of the joint is indicated by
increased motion.
 Compartment Syndrome
• Most commonly occurs in a fractured tibia or
forearm of children
• Elevated pressure within a fascial compartment
• Develops within 6 to 12 hours after injury
• Pain out of proportion with injury
• Splint affected limb, keeping it at the level of the
heart.
• Provide immediate transport.
 Severity of Injury
• Critical injuries can be identified using
musculoskeletal injury grading system.
 Minor Injuries
• Minor sprains
• Fractures or dislocations of digits
 Moderate Injuries
• Open fractures of the digits
• Nondisplaced long bone fractures
• Nondisplaced pelvic fractures
• Major sprains of a major joint
 Serious Injuries
• Displaced long bone fractures
• Multiple hand and foot fractures
• Open long bone fractures
• Displaced pelvic fractures
• Dislocations of major joints
• Multiple digit amputations
• Laceration of major nerves or blood vessels
 Severe Life-Threatening Injuries
(Survival Is Probable)
• Multiple closed fractures
• Limb amputations
• Fractures of both long bones on the leg (bilateral
femur fractures)
 Critical Injuries
(Survival Is Uncertain)
• Multiple open fracture of the limbs
• Suspected pelvic fractures with hemodynamic
instability
• You and your EMT-B partner are dispatched to the
local skateboarding rink for a fall injury.
• The scene is safe.
• You find an 18-year-old male who is holding his left
arm close to his chest.
• He appears to be in a lot of pain.
You are the Provider
• He is conscious, alert, and oriented with no
external bleeding.
• What is the mechanism of injury?
• What questions should you ask to determine the
patient’s possible injury?
• Should you stabilize the patient’s c-spine?
• What could you do to ease the patient’s pain?
You are the provider continued
 Scene Size-up

• Carefully assess the MOI.

• Observe for hazards and threats to safety; take BSI
precautions.
• Consider the need for spinal stabilization.
• Evaluate the need for law enforcement.
• Consider requesting ALS backup.
 Initial Assessment (1 of 2)

• Ask patient’s chief complaint; assess level of

consciousness.
• Ask about MOI.
• Injuries to head may cause inadequate breathing.
• You may administer oxygen to relieve anxiousness
and improve perfusion.
• Do not let the injury distract you from caring for
ABCs.
 Initial Assessment (2 of 2)

• Treat patient for shock if signs of hypoperfusion are

present.
• Bandage bleeding extremities with sterile dressings
to control bleeding
– Do not make so tight as to restrict distal
circulation.
• Monitor bandage tightness by assessing
circulation, sensation, and movement distal to
injury.
• Swelling may cause bandage to become too tight.
 Transport Decision
• Provide rapid transport if patient has airway or
breathing problems.
• If patient had significant MOI, transport rapidly
even if patient seems okay.
• Stabilize patient on a backboard.
• You assess ABCs, take c-spine precautions, and
provide oxygen via nonrebreathing mask.
• Patient is a low-priority transport.
• He tells you he fell while on a skateboard. He used
his right arm to break the fall.
• Heard a “pop” when he hit the concrete. Denies
hitting his head or losing consciousness.
• Right forearm is angulated slightly in the middle.
He asks you not to touch it. You are the provider continued
• After your initial assessment, what should you do?
• Describe the next phase of your assessment.
You are the provider
continued
 Focused History and Physical
Exam

• Use DCAP-BTLS.
• Contusions, abrasions, or tenderness may be only
signs of an underlying injury.
 Rapid Physical Exam for
Significant Trauma
• If you find no external signs of injury, ask patient to
move each limb carefully, stopping immediately if
this causes pain.
• Skip this step if the patient reports neck or back
pain. Slight movement could cause permanent
damage to spinal cord.
 Focused Physical Exam for
Nonsignificant Trauma
• Evaluate circulation, motor function, sensation.
• If two or more extremities are injured, transport.
– Severe injuries more likely if two or more bones
have been broken
• Recheck neurovascular function before and after
splinting.
• Impaired circulation can lead to death of the limb.
Assessing Neurovascular Status (1 of 4)
• If anything causes pain,
do not continue that
portion of exam.
• Pulse
– Palpate the radial,
posterior tibial, and
dorsalis pedis
pulses.
Assessing Neurovascular Status (2 of 4)
• Capillary refill
– Note and record skin
color.
– Press the tip of the
fingernail to make
the skin blanch. If
normal color does
not return within 2
seconds, you can
assume that
circulation is
impaired.
Assessing Neurovascular Status (3 of 4)
• Sensation
– Check feeling on the flesh near the tip of the
index finger.
– In the foot, check the feeling on the flesh of the
big toe and on the lateral side of the foot.
Assessing Neurovascular Status (4 of 4)
• Motor function
– Evaluate muscular activity when the injury is
near the patient’s hand or foot.
– Ask the patient to open and close his or her fist.
– Ask the patient to wiggle his or her toes.
 Baseline Vital Signs/
SAMPLE History
• Obtain baseline vital signs as soon as possible.
• Shock is common.
• Attempt to obtain SAMPLE history without delaying
transport.
• Extent of history depends on how quickly you need
to transport.
 Interventions
• Stabilize ABCs.
• Control serious bleeding.
• Secure patient to a backboard if critically injured.
• Provide prompt transport.
• If patient is not critically injured, splint on scene.
• Goal is to stabilize injury in most comfortable
position that allows for maintenance of good
circulation distal to site.
• You begin a focused physical exam.
• You note tenderness, swelling, and crepitus with
gentle palpation in the right mid-forearm.
• Patient can feel you touch his fingers. Distal pulse
is found. Capillary refill is normal.
• Your partner manually stabilizes the injured
extremity. You begin the SAMPLE history and
assess vital signs. You are the provider continued (1 of 2)
• Describe your emergency care.
You are the provider continued (2
of 2)
 Detailed Physical Exam

• Inspect and gently palpate other extremities and

the spine to identify underlying fractures,
dislocations, or sprains.
• Compare injured limb to opposite, uninjured limb.
 Ongoing Assessment

• Repeat initial assessment and vital signs.

• Reassess interventions.
• Reassess neurovascular function and color of
splinted injured extremity distal to injury site.
• Communication and documentation
– Report problems with ABCs, type of fracture,
and if circulation was compromised before or
after splinting.
– Document complete descriptions of injuries and
MOIs.
 Emergency Medical Care
• Completely cover open wounds.
• Apply the appropriate splint.
• If swelling is present, apply ice or cold packs.
• Prepare the patient for transport.
• Always inform hospital personnel about wounds
that have been dressed and splinted.
 Splinting
• Flexible or rigid device used to protect
extremity
• Injuries should be splinted prior to moving
patient, unless the patient is critical.
• Splinting helps prevent further injury.
• Improvise splinting materials when
needed.
 General Principles of Splinting (1 of 3)
• Remove clothing from
the area.
• Note and record the
patient’s neurovascular
status.
• Cover all wounds with a
dry, sterile dressing.
• Do not move the patient
before splinting.
 General Principles of Splinting (2 of 3)
• Immobilize the joints above
and below the injured joint.
• Pad all rigid splints.
• Apply cold packs if swelling
is present.
• Maintain manual
immobilization.
• Use constant, gentle,
manual traction if needed.
• If you find resistance to limb
alignment, splint the limb as
is.
 General Principles of Splinting (3 of 3)
• Immobilize all suspected
spinal injuries in a neutral
in-line position.
• If the patient has signs of
shock, align limb in
normal anatomic position
and transport.
• When in doubt, splint.
 In-line Traction Splinting
• Act of exerting a pulling force on a bony
structure in the direction of its normal
alignment.
• Realigns fracture of the shaft of a long bone.
• Use the least amount of force necessary.
• If resistance is met or pain increases, splint in
deformed position.
 Applying a Rigid Splint (1 of 2)
• Provide gentle support
and in-traction of the
limb.
• Another EMT-B places
the rigid splint alongside
or under the limb.
• Place padding between
the limb and splint as
needed.
 Applying a Rigid Splint (2 of 2)
• Secure the splint to the
limb with bindings.
• Assess and record
distal neurovascular
function.
 Applying a Zippered Air Splint
• Hold the injured limb, apply
gentle traction and support the
injury site.
• Partner should place splint
around extremity.
• Zip up the splint.
• Inflate by pump or mouth.
• Test the pressure in the splint.
• Check and record distal
neurovascular function.
 Applying an Unzippered Air Splint
• Support limb.
• Place arm through splint and
grasp hand or foot of injured limb.
• Apply gentle traction to hand or
foot while sliding splint onto
injured limb.
• Inflate by pump or mouth.
• Test pressure.
• Check and record pulse, motor,
and sensory function and
monitor.
 Applying a Vacuum Splint
• Stabilize and support the injury.
• Place the splint and wrap it around the limb.
• Draw the air out of the splint and seal the valve.
• Check and record distal neurovascular function.
 Traction Splints
• Do not use a traction splint under the following
conditions:
– Upper extremity injuries
– Injuries close to or involving the knee
– Pelvis and hip injuries
– Partial amputation or avulsions with bone
separation
– Lower leg, foot, or ankle injuries
 Applying a Hare Traction Splint (1 of 3)

• Expose the injured limb

and check pulse, motor,
and sensory function.
• Place splint beside the
uninjured limb, adjust to
proper length, and
prepare straps.
• Support the injured limb
as your partner fastens
the ankle hitch.
 Applying a Hare Traction Splint (2 of 3)

• Continue to support the limb as your partner

applies gentle in-line traction to the ankle hitch and
foot.
• Slide the splint into position under the injured limb.
• Pad the groin and fasten the ischial strap.
 Applying a Hare Traction Splint (3 of 3)
• Connect loops of ankle hitch to end of splint as your
partner continues traction.
• Carefully tighten ratchet to the point that splint holds
adequate traction.
• Secure and check support straps.
• Assess distal neurovascular function.
• Secure the patient and splint to long board for
transport.
Applying a Sager Traction Splint (1 of 3)
• Expose the injured extremity and check pulse, motor,
and sensory function.
• Adjust the thigh strap of the splint.
• Estimate the proper splint length.
• Fit the ankle pads to the patient’s ankle.
• Place the splint along the inner thigh.
Applying a Sager Traction Splint (2 of 3)
• Secure the ankle harness.
• Snug the cable ring against the bottom of the foot.
• Pull out the inner shaft of the splint to apply
traction.
Applying a Sager Traction Splint (3 of 3)
• Secure the limb to the splint.
• Secure patient to a long backboard.
• Check pulse, motor, and sensory function.
 Hazards of Improper Splinting
• Compression of nerves, tissues, and blood
vessels
• Delay in transport of a patient with a life-
threatening condition
• Reduction of distal circulation
• Aggravation of the injury
• Injury to tissue, nerves, blood vessels, or
muscle
 Clavicle and Scapula Injuries
• Clavicle is one of the
most fractured bones in
the body.
• Scapula is well protected
• Joint between clavicle
and scapula is the
acromioclavicular (A/C)
joint
• Splint with a sling and
swathe.
 A/C Separation
With A/C separation, the
distal end of the clavicle
usually sticks out.
Dislocation of the Shoulder (1 of 3)
• Most commonly
dislocated large joint
• Usually dislocates
anteriorly
• Is difficult to
immobilize
 Dislocation of the Shoulder (2 of 3)
A patient with a dislocated
shoulder will guard the
shoulder, trying to protect
it by holding the arm in a
fixed position away from
the chest wall.
 Dislocation of the Shoulder (3 of 3)
• Splint the joint with a
pillow or towel between
the arm and the chest
wall.
• Apply a sling and a
swathe.
 Fractures of the Humerus
• Occurs either proximally, in
the midshaft, or distally at the
elbow.
• Consider applying traction to
realign a severely angulated
humerus, according to local
protocols.
• Splint with sling and swathe,
supplemented with a padded
board splint.
 Elbow Injuries
• Fractures and dislocations often occur around the
elbow.
• Injuries to nerves and blood vessels common.
• Assess neurovascular function carefully
– Realignment may be needed to improve circulation.
 Fractures of the Forearm (1 of 2)
• Usually involves both
radius and ulna
• Use a padded board, air,
vacuum, or pillow splint.
 Fractures of the Forearm (2 of 2)
• A fracture of the distal
radius produces a
characteristic silver fork
deformity.
 Injuries to the Wrist and Hand
• Follow BSI precautions.
• Cover all wounds.
• Form hand into the position of function.
• Place a roller bandage in palm of hand.
• Apply padded board splint.
• Secure entire length of splint.
• Apply a sling and swathe.
 Fractures of the Pelvis
• May involve life-threatening internal bleeding
• Assess pelvis for tenderness.
• Stable patients can be secured to a long
backboard or scoop stretcher to immobilize
isolated fractures of the pelvis.
 Assessment of Pelvic Fractures
• If there is injury to the bladder or urethra, the
patient may have lower abdominal tenderness.
• They may have blood in the urine (hematuria) or at
the urethral opening.
 Stabilizing Pelvic Fractures
• A stable patient with a
pelvic fracture may be
placed on a long board.
• If the patient is unstable,
consider using a PAGS
with the patient stabilized
on the long board
(consult your local
protocols).
 Dislocation of the Hip
• Hip dislocation requires significant mechanism of
injury.
• Posterior dislocations lie with hip joint flexed and
thigh rotated inward
• Anterior dislocations lie with leg extended straight
out, and rotated, pointing away from midline.
• Splint in position of deformity and transport.
Fractures of the Proximal Femur (1 of 2)
• Presents with very characteristic deformity
• Fractures from trauma injuries best managed with
traction splint or PASG and a backboard.
• Isolated fracture in geriatric patients can be managed
with long backboard or a scoop stretcher.
Fractures of the Proximal Femur (2 of 2)
• A proximal femur
fracture will be rotated.
• Splint the injured leg to
the uninjured leg and
secure the patient to a
scoop stretcher or
backboard.
 Femoral Shaft Fractures
• Muscle spasms can cause deformity of
the limb
• Significant amount of blood loss will
occur.
• Stabilize with traction splint.
 Injuries of Knee Ligaments
• Knee is very vulnerable to
injury.
• Patient will complain of
pain in the joint and be
unable to use the
extremity normally.
• Splint from hip joint to
foot.
• Monitor distal
neurovascular function.
 Dislocation of the Knee
• Produces significant deformity
• More urgent injury is to the popliteal artery,
which is often lacerated or compressed.
• Always check distal circulation.
 Fractures About the Knee
• If there is adequate distal pulse and no
significant deformity, splint limb with knee
straight.
• If there is adequate distal pulse and significant
deformity, splint joint in position of deformity.
• If pulse is absent below level of injury, contact
medical control immediately.
 Dislocation of the Patella
• Usually dislocates to
lateral side.
• Produces significant
deformity.
• Splint in position found.
• Support with pillows.
Injuries to the Tibia and Fibula (1 of 2)
• Usually, both bones fracture at the same time.
• Open fracture of tibia common.
• Stabilize with a padded rigid long leg splint or
an air splint that extends from the foot to upper
thigh.
 Injuries to the Tibia and Fibula (2 of 2)
Because the tibia is so
close to the skin, open
fractures are quite
common.
 Ankle Injuries
• Most commonly injured
joint
• Dress all open wounds.
• Assess distal
neurovascular function.
• Correct any gross
deformity by applying
gentle longitudinal
traction to the heel.
• Before releasing traction,
apply a splint.
 Foot Injuries
• Usually occur after a patient falls or jumps.
• Immobilize ankle joint and foot.
• Leave toes exposed to assess neurovascular
function.
• Elevate foot 6”.
• Also consider possibility of spinal injury from a fall.
 Injuries from Falls
Frequently after a fall, the
force of the injury is
transmitted up the legs to
the spine, sometimes
resulting in a fracture of
the lumbar spine.
 Foot Stabilization
A pillow splint can provide
excellent stabilization of
the foot.