EMT: Ch 28 Musculoskeletal Injuries

Caring for Patient with Dislocated Hip

- CSM - long board - immobilize limb and secure patient to board - reassess CSM - O2 - continue to monitor vitals and CSM on transport

Traction splint

- Two types: Bipolar (Hare or Fernotrac) vs. Unipolar (Sager or the Kendrick) - Indications: fractured mid-femur - Contraindications: - pelvis, hip or knee injury - avulsion or partial amputation

Splinting risks

- an unstable patient - too loose - too tight

Hip dislocation

- displacement of head of femur out of acetabulum - can be anterior or posterior dislocation - more common with prosthetic hip - anterior dislocation: lower limb is rotated outward and appears in flexion - posterior dislocation: lower limb rotated inward, hip flexed and knee flexed, may have associated neuro deficit to affected leg.

Splinting

- life threatening problems first - expose injury - assess CSM - align to anatomical position - don't push exposed bones back in - immobilize to include joint above and joint below - splint before moving patient if possible - pad the voids

Presentation of Hip fracture

- localized pain - tenderness over greater trochanter - discoloration - swelling - unable to move limb - unable to stand - foot rotated - shortening of limb

Caring for patient with Pelvic fractures

- move patient as little as possible (log roll on opposite side) - assess CSM - straighten legs only if no other lower extremity injury - stabilize lower limbs (using folded blanket) - pelvic stabilization (a little pressure) - secure patient to long back board - reassess CSM - apply high concentration O2 (shock) - transport ASAP don't move knees too much to avoid spine injury

Caring for patient with hip fracture

- primary survey and assess CSM - bind legs together, Use pillows or blanket folded between legs and under the knees as necessary on long board - splint affected limb with padded boards - apply an anti-shock garment only if your service protocols indicate

Caring for patient

- standard precautions - primary assessment - during secondary assessment; C-collar if indicated - splinting vs. load and go - cover open wounds

Splinting Elbow injuries

1. Assess the patient. Assess distal circulation, sensation, and motor function. Move the limb only if necessary for splinting or if the pulse is absent. Stop if you meet resistance or significantly increase the pain. 2. Use a padded board splint that will extend from the armpit to the fingers. Pad the armpit. 3. Make sure the distal end of the splint is placed so that the fingers curl around it in a natural way, approximating as nearly as possible the position of comfort. 4. Secure the padded splint to the forearm with gauze bandaging. 5. Secure the upper arm and place additional padding between the splint and the patient's body. 6. Secure the splinted limb to the body with two cravats. Avoid placing the cravats over the suspected injury site. Reassess the distal circulation, sensation, and motor function (CSM).

Joint

A place in the body where two bones come together; have a capsule

Applying a Sling and Swath

A sling is a triangular bandage used to support the shoulder and arm. Once the patient's arm is placed in a sling, a swathe can be used to hold the arm against the side of the chest. Commercial slings are available. Velcro straps can be used to form a swathe. Use whatever materials you have on hand, provided they will not cut into the patient. Also, remember to assess distal pulse, motor function, and sensation both before and after immobilizing or splinting an extremity 1. Prepare the sling by folding cloth into a triangle. 2. Position the sling over the top of the patient's chest as shown. Fold the injured arm across his chest. If the patient cannot hold his arm, have someone assist him until you tie the sling. 3. Extend one point of the triangle beyond the elbow on the injured side. Take the bottom point and bring it up over the patient's arm. Then take it over the top of the injured shoulder. 4. If appropriate, draw up the ends of the sling so the patient's hand is about 4 inches above the elbow. 5. Tie the two ends of the sling together, making sure that the knot does not press against the back of the patient's neck. Pad with bulky dressings. (If spine injury is possible, pin the ends to the patient's clothing. Do not tie them around the neck.) 6. Check to be sure you have left the patient's fingertips exposed. Then assess distal circulation, sensation, and motor function (CSM). If the pulse has been lost, take off the sling and repeat the procedure. Then check again. 7. To form a pocket for the patient's elbow, take hold of the point of material at the elbow and fold it forward, pinning it to the front of the sling. Or If you do not have a pin, twist the excess material and tie a knot in the point. 8. Form a swathe from a second piece of material. Tie it around the chest and the injured arm, over the sling. Do not place it over the patient's arm on the uninjured side. 9. Reassess distal CSM. Take vital signs. Perform detailed assessments and reassessments as appropriate.

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.

ankle or foot car

Assess distal CSM. Stabilize the limb. Remove the patient's shoe if possible, but only if it removes easily and can be done with no movement to the ankle. Lift the limb but do not apply manual traction (tension). Place three cravats on the floor under the ankle. Then place a pillow lengthwise under the ankle on top of the cravats. The pillow should extend 6 inches beyond the foot. Gently lower the limb onto the pillow, taking care not to change the ankle's position. Stabilize by tying the cravats, and adjust them so they are at the top of the pillow, midway, and at the heel. Tie the pillow to the ankle and foot. Tie a fourth cravat loosely at the arch of the foot. Elevate with a second pillow or blanket. Reassess distal CSM. Care for shock (hypoperfusion) if needed. Apply an ice pack to the injury site to reduce bleeding and swelling if appropriate. Do not apply the ice pack directly to the skin.

shoulder girdle injury

Assess distal CSM. If distal CSM is impaired, immobilize and transport as soon as possible, notifying the receiving facility. It is not practical to use a rigid splint for injuries to the clavicle, scapula, or the head of the humerus. Use a sling and swathe (Scan 28-4). If there is a possible cervical-spine injury, do not tie a sling around the patient's neck. If there is evidence of a possible anterior dislocation of the head of the humerus (the bone head is pushed toward the front of the body), place a thin pillow between the patient's arm and chest before applying the sling and swathe. Do not attempt to straighten or reduce any dislocations. Reassess distal CSM.

Appendicular skeleton

Bones of the limbs and limb girdles that are attached to the axial skeleton

Assessment of patient

Don't be distracted by deformity: - pain and tenderness - swelling - bruising - deformity - grating or crepitus - exposed bone ends - joints are locked (splint) - nerve and vessel compromised check for CMS

Anatomy of Bone

Epiphysis (end) and Diaphysis (middle), articular cartilage on end, ephiphyseal line (separates spongy bone), medullar cavity, nutrient foramen, endosteum, periosteium

When to splint

Forearm. Deformity and tenderness. If only one bone is broken, deformity may be minor or absent. Wrist. Deformity and tenderness. Hand. Deformity and pain. Dislocated fingers are obvious.

Compact bone

Hard, dense bone tissue that is beneath the outer membrane of a bone

SPLINT, SLING, AND SWATHE:

Injuries occurring to the forearm, wrist, or hand can be splinted using a padded rigid splint that gives support from elbow to hand. The patient's elbow, forearm, wrist, and hand all need the support of the splint. Tension must be provided throughout the splinting. A roll of bandages should be placed in the patient's hand to ensure the position of function. After rigid splinting, apply a sling and swathe.

PILLOW SPLINT

Injuries to the hand and wrist can be cared for with soft splinting by placing a roll of bandages in the hand to maintain the position of function, then tying the forearm, wrist, and hand into the fold of one pillow or between two pillows.

Pelvic wrap

Once you determine the patient is a candidate for a pelvic wrap (unstable pelvis with or without signs of shock or MOI), prepare a backboard with a sheet, folded flat, approximately 10 inches wide and lying across the backboard (Figure 28-18B). Carefully roll the patient to the backboard. Center the sheet at the patient's greater trochanter (the bony prominence at the proximal end of the femur). This will position the sheet lower than the iliac "wings." This is the correct position. Bring the sides of the sheet around to the front of the patient (Figure 28-18C). As you bring the sides of the sheet together and tie them, you will cause compression and stabilization of the pelvis. The sheet should feel firm enough on the pelvis to keep it in normal position without overcompression secure the sheet using ties or clamps so the compression is maintained.

Pelvic stabilization

Pelvic wrap vs. pneumatic anti-shock garment

Axial skeleton

Portion of the skeletal system that consists of the skull, rib cage, and vertebral column

extensor

The muscle that opens a joint

Splinting a humeral injury

Variation one: Apply a sling and swathe, If you have only enough material for a swathe, bind the patient's upper arm to her body, taking great care not to cut off circulation to the forearm. Variation two: If you have only a narrow or short length of material to use as a sling, apply it so that it supports the wrist only.

Two Splint method

You can immobilize the fracture using two rigid board splints 1. Assess the distal CSM. Measure the splints. They should extend above the knee and below the ankle. 2. Apply manual traction (tension) on the leg; then place one splint medially and one laterally. Padding is toward the leg. 3. Secure the splints, padding the voids. 4. Reassess distal CSM. 5. Reassess for shock and administer high-concentration oxygen as appropriate. Transport on a long spine board.

distracted fracture

a fracture in which the distal fragment is separated from the proximal fragment by a gap

flexor

a muscle that bends a part of the body, such as an arm or a leg

pelvic fractures

assoc with falls, MVC, or crush injuries symptoms: pain in pelvis hips or groin unable to lift legs fullness in bladder blood at penis or vagina damaged nerves possible associated spinal injuries hip is technically part of the femur (proximal part of femur)

ligaments connect bone to

bone

Comminuted fracture

bone broken or splintered into pieces

dislocation

displacement of a bone from its joint

angulated fracture

fracture in which the broken bone segments are at an angle to each other; angulated fragments

Femoral shaft fracture

high intensity pain swelling limb shortening apply pressure high O2 for shock apply splint

Greenstick fracture

incomplete fracture

sprain

injury to a ligament

disruptions of tendon results in:

loss of joint function

tendons connect ___ to bone

muscle

strain

muscle/tendon damaged

Fracture

open vs. closed (intact skin); proximal, distal, or midshaft

Lower Extremity injuries

pelvis fractures, hip dislocations, hip fractures, knee injuries, tibial and fibial fractures, and ankle or foot injuries

knee injury

should be splint in position found

pelvic fracture

stabilize pelvis to avoid further bleeding or internal damage

overriding fracture

the slipping of either part of a fractured bone past the other