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Musculoskeletal Injuries

You respond to a soccer field for an
“accidental injury.” Your patient is a
33-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.
 What exam findings would lead you to
believe that perfusion to the extremity is

 Describe actions that should be taken

immediately to improve blood flow to the

 How will you determine if your actions are


 What anatomical structures are likely

involved in this injury?
Introduction to Musculoskeletal Injuries

 Millions of Americans experience

 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
 Diminution of bone strength

 Spinal curvature
Anatomy & Physiology of the
Musculoskeletal System
 Muscular Tissue
& Structure
 600 muscle
 Types of
 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
 Insertion: More movable and distal
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
 Regulates size of lumen of tubular
 Contractions strong and slow
Cardiac Muscles

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
Cardiac Muscles

 Myocardium
 Forms middle layer of

 Innervated by
autonomic nervous
system but contracts
spontaneously without
any nerve supply

 Contractions are
strong and rhythmic
 Bands of connective tissue
 Bind muscles to bones

 Allow for power of movement across


 Supplied by sensory fibers that

extend from muscle nerves
 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

 Connective tissue covering epiphysis

 Surface for articulation

 Allows for smooth movement at

 Connective tissue that crosses joints

 Attaches bone to bone

 Stretch more easily than tendons

 Allow for stable range of motion

 Dense fibrous connective tissue

 Forms bands or sheets

 Covers muscles, blood vessels, and


 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
Pathophysiology — Mechanism of
Five forces cause bone and joint injury
 Direct force
 Indirect force
 Twisting force
 Pathological
 Fatigue
Classifications of Musculoskeletal
 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
Impacted — Jammed together so there is no
movement between proximal and distal
Open — Skin is open, allowing
introduction of bacteria, dirt, and
other foreign bodies
Closed — Skin is intact
Fracture with dislocation — Fracture at
 Break in continuity of bone or

 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
Classification of Fractures
 Oblique

 Transverse

 Stress

 Pathological

 Epiphyseal
Classification of Fractures
Pathophysiology — Fractures
Pathophysiology — Fractures
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

Pathophysiology — Fractures
Dislocation - Angulated
Pathophysiology — Fractures
 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
 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
 Inflammatory & Degenerative
 Bursitis
 Tendinitis
 Arthritis
 Osteoarthritis
 Degenerative
 Rheumatoid Arthritis
 Chronic, systemic, progressive, debilitating
 Gout
 Inflammation of joints produced by accumulation
of uric acid crystals
 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 is usually from:
 Pressure
 Friction
 Injury to membranes surrounding the

 Treatment
 Rest, ice, and analgesics
 Inflammation of tendon
 Often caused by injury

 Symptoms include:
 Pain
 Tenderness
 Restricted movement of muscle attached to affected

 Treatment
 Nonsteroidal antiinflammatory drugs (NSAIDs)
 Corticosteroid medications
 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
 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
 Pain
 On palpation (tenderness)
 On movement
 Pallor—pale skin or poor capillary
 Paresthesia—pins and needles
 Pulses—diminished or absent
 Paralysis—inability to move
 Pressure
Associated Complications
 Hemorrhage

 Instability

 Loss of tissue

 Simple laceration and contamination

 Interruption of blood supply

 Nerve damage

 Long-term disability
 Determine if life-threatening
conditions are present
 Care for those first

 Never overlook musculoskeletal


 Don’t allow noncritical

musculoskeletal injury to distract
Musculoskeletal Assessment
 Four classes of patients
 Life-/limb-threatening injuries or
 Includes life-/limb-threatening
musculoskeletal trauma
 Other life-/limb-threatening injuries and
simple musculoskeletal trauma
 Life-/limb-threatening musculoskeletal
 No other life-/limb-threatening injuries
 Isolated, non-life-/limb-threatening
Musculoskeletal Injury Assessment
 Scene Size-up
 Initial Assessment
 Categories of urgency
 Life & Limb threatening injury
 Life threatening injury and minor musculoskeletal
 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
 Increased risk of disk herniation
 Loss of stature is common – ½ - 3/4
 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


 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

 Fluid Resuscitation

 Femur
 Traction Splints

 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

 Foot Injuries
 Shoulder
 Elbow Alert for
 Wrist/Hand PMS

Musculoskeletal Injury Management

 Soft & Connective Tissue Injuries

 Tendon
 Ligament
 Muscle
Musculoskeletal Injury Management
Not A Biotel Option
 Nitrous Oxide  Diazepam
 50% O2:50% N  Benzodiazepine
 Non-explosive  Antianxiety
 Effects dissipate in  Analgesic
2-5 minutes  Dose
 Easily diffused into  5-15 mg titrated
air filled spaces in  Onset
body.  10-15 minutes
 Dose  Duration
 Inhaled & self
 15-60 minutes
administered  Counter Agent
 Onset  Flumazenil
 1-2 minutes
Dislocation of Acromioclavicular
Humerus Injury
 Older adults and

 Difficult to stabilize

 Complications
 Radial nerve damage
if fracture in middle
or distal portion of
humeral shaft
 Humeral neck
fracture may cause
axillary nerve
 Internal hemorrhage
into joint
Posterior Dislocation of the Elbow
Joint with Marked Deformity
Severe Open Fracture of
Penetration of Forearm Caused by Nail
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

 Oxygen
n Nitrous Oxide
n 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
self-administer 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

Dose: Adult: Administer in titrated doses of 2 -
4mg, up to a maximum of 10mg
Pediatric: 0.1mg/kg

Drug Action: Alleviates pain

 Decreases peripheral vascular resistance -
 Decreases cardiac workload and oxygen demand
on the heart