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Scaffolding/Support
Protection of vital organs
Locomotion
Production of RBC
Storage of minerals
Musculoskeletal Structures
Skin
Muscles
Bones
Tendons
Ligaments
Cartilage
Musculoskeletal Structures -
Skin
Holds all structures together
Barrier function
Protects underlying structures
Subcutaneous tissue
– Fat
– Fascia
Further discussion in Soft-Tissue Trauma
Musculoskeletal Structures -
Muscle
Composed of specialized cells with ability
to contract
Voluntary (Skeletal)
– Conscious control
– Allows mobility
Smooth (Bronchi, GI tract, blood vessels)
– Controlled by ANS
– Able to alter inner lumen diameter
Cardiac
– Contracts rhythmically on its own
Musculoskeletal Structures -
Muscle
Can only contract
Skeletal muscle causes movement by
shortening resulting in pulling on bones
through cord like bands
Musculoskeletal Structures
Tendons
– Bands of connective tissue binding muscles to
bones
Cartilage
– Connective tissue covering the epiphysis
– Surface for articulation
Ligaments
– Connective tissue supporting joints
– Attach bone ends to each other
Bones
Living tissue
Consists of cells which deposit
calcium, phosphorus on protein matrix
Constantly remodels itself
Able to repair damage without
formation of scar tissue
Bones
Diaphysis
– Long, narrow shaft
– Dense, compact bone
Metaphysis
– Head of bone
– Between epiphysis and diaphysis
Medullary canal
– Contains marrow
Long Bone Anatomy
Periosteum
– Outer fibrous covering
– Allows for increase in diameter
– Vascular
– Nerves
Epiphysis
– Articulated, widened end
– Allows bone to lengthen
– Cancellous bone with red blood marrow
– Weakest point in child’s bone
Joints
Ball/Socket
– Shoulder/Hip
Hinge
– Elbow/Knees/Fingers/TMJ
Pivot
– Between radius and ulna
Gliding
– Bones of wrist
Fracture
Direct
– Break occurs at point of impact
Indirect
– Force is transmitted along bone
– Injury occurs at some point distant to point of impact
– Femur, hip, pelvic fracture due to knees hitting dash
Mechanism of Injury
Twisting
– Distal limb remains fixed
– Proximal part rotates
– Shearing, fracturing occur
– Football. skiing accidents
Avulsion
– Muscle and tendon unit with attached fragment of
bone ripped off bone shaft
Mechanism of Injury
Stress
– Occur in feet secondary to prolonged running
or walking
Pathological
– Result of Fx with minimal force
– Cancer, osteoporosis
Fracture Descriptions
Open vs Closed
X-Ray descriptions
– greenstick
– oblique
– transverse
– comminuted
– spiral
– impacted
– epiphyseal
Fracture Types
Transverse
– Cuts shaft at right angle to long axis
– Often caused by direct injury
Greenstick
– Pliable bone splinters on one side without
complete break
– Occurs in children
Fracture Types
Spiral
– Fx site coils through bone like spring
– Occurs with torsion
Oblique
– Occurs at angle to long axis of shaft
Comminuted
– Bone broken into 3 or more pieces
Fracture Type
Impacted
– Bone ends jammed together
– Occurs with compression
– Frequently no loss of function
Problems Associated with
Musculoskeletal Injuries
Hemorrhage
Interruption of Blood Supply
Disability
Instability
Soft Tissue injury
Complications associated with
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
Complications associated with
Fractures
Disability
– Diminished sensory or motor function
» inadequate perfusion
» direct nerve injury
Specific Injuries
– Dislocation
– Amputation/Avulsion
– Crush Injury (soft tissue trauma discussion)
Sprains/Strains
Sprain
– tearing of ligaments surrounding joint
Strain
– overstretching of muscle or tendon
Musculoskeletal Assessment
The possibilities
– Life-threatening injuries or conditions,
including life/limb threatening musculoskeletal
trauma
– Life/Limb threatening injuries and only simple
musculoskeletal trauma
– Life/Limb threatening musculoskeletal trauma
and no other life/limb threatening injuries
– Only isolated, non-life/limb threatening
injuries
Musculoskeletal Assessment
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
Musculoskeletal Assessment
Immobilization Objectives
– Prevent further damage to nerves/blood vessels
– Decrease bleeding, edema
– Avoid creating an open Fx
– Decrease pain
– Early immobilization of long bone fractures
critical in preventing fat embolism
Management - 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
Management - 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
Management - General
Pain Management
– Avoid pain management until head/thoracic
injury is ruled out
– Appropriate for isolated musculoskeletal
injuries (fracture/sprain/dislocation)
– Underutilized
– Morphine sulfate titrated to pain relief without
compromising adequate BP and ventilations
Management - Pediatric
Evaluation of neurovascular
deficiencies in distal extremity
Dislocations
Stretching.tearing of ligaments
surrounding joint
Occur when joint is twisted beyond normal
range of motion
Most common = Ankle
Sprain Management
Characteristics
– Pain
– Tenderness
– Swelling
– Discoloration
Typically does not manifest deformity
Ice, compression, elevation, immobilize
When in doubt, splint
Consider analgesia
Strains
Shaft of Humerus
– Usually obvious due to deformity
– Wrist drop may occur
– Vascular compromise may be present
Upper Extremity Fx
Anterior
– Blow to abducted leg, external rotation of
affected extremity
Posterior
– Blow to flexed/Abducted knee
– More severe than anterior dislocation
– Associated with rupture of joint capsule,
acetabular Fx, sciatic nerve injury
Management - Hip Dislocation
Realignment
– One attempt if severe neurovascular compromise
– Do not attempt if associated with other severe
injuries
– Provide analgesia
– Steady and slow pull along shaft of femur
– If successful, “pops” into joint, sudden relief of
pain, leg can easily return to extension
Immobilization
– Flexion of hip/knee for comfort acceptable
Pelvic Fracture
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)
– What if time (patient instability) does not allow
for traction splint application?
Lower Extremity Fx
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
Management - Lower Extremity
Fx
Patellar, Tibia/Fibula, and Calcaneal
– Assess for neurovascular impairment
– Realign long bones
– Splinting possibilities
» board splint or cardboard splint
» vacuum splint
» pillow
Elbow Dislocation
Presentation
– High neurovascular traffic
– Volkmann’s contracture - ischemia secondary to
trauma causes ischemic contractions
Management
– assess for neurovascular impairment
– sling
– swathe
– analgesia and position of comfort
Knee Dislocation
Presentation
– Trauma to popliteal artery
– Many reduce spontaneously
– Knee dislocation has a 50% incidence of
associated vascular injury
– Presence of distal pulse does not rule out
vascular injury
Management - Knee Dislocation
Management
– Assess for neurovascular impairment
– One attempt at realignment if impairment or delayed
transport
– Do not realign if associated with other severe injuries
– analgesia and position of comfort
– gentle, steady traction to move into normal position
» success by “pop” into joint, less deformity and pain, and
increased mobility
Hemorrhage Management
Direct Pressure
– Most effective method
– Pressure bandage
Elevation
– Combination with direct pressure
Pressure Point
– Brachial, Femoral, Carotid
Tourniquet
– last resort
– rarely required
Tourniquet