Emergency Care Textbook Professional Responders-part-10.pdf

10 Musculoskeletal Injuries Key Content Types of Musculoskeletal Injuries.................................. Splints...................................... Slings........................................ Signs and Symptoms of Musculoskeletal Injuries...... Care for Musculoskeletal Injuries................

10 Musculoskeletal Injuries Key Content Types of Musculoskeletal Injuries.................................. Splints...................................... Slings........................................ Signs and Symptoms of Musculoskeletal Injuries...... Care for Musculoskeletal Injuries.................................. Upper Extremity Injuries........ Lower Extremity Injuries........ 196 198 201 201 203 204 208 Injuries to the musculoskeletal system occur in a variety of ways. They are most commonly caused by forces generated by mechanical energy, but they can also result from exposure to excessive heat, chemicals, or electricity. Injuries to muscles and related tissues such as tendons and ligaments are technically soft tissue injuries, but the close relationship between these tissues and the skeleton make it more useful to consider musculoskeletal injuries separately. Although musculoskeletal injuries are typically painful, they are rarely life-threatening. However, when not recognized and treated promptly, they can result in permanent disability or death. Musculoskeletal injuries are especially dangerous when a bone breaks and the fractured ends cause damage to other internal structures such as vital organs or blood vessels. They are also dangerous when a displaced part of the bone puts pressure on blood vessels, resulting in vascular compromise and MUSCULOSKELETAL INJURIES Introduction 195 tissue death. In these cases, the soft tissue injury is the life-threatening condition, but the cause is the fracture. Cracked bone TYPES OF MUSCULOSKELETAL INJURIES Injuries to the musculoskeletal system can be classified according to the type of structure that is damaged. Injuries are also classified by the nature and extent of the trauma caused to the body. The four basic types of musculoskeletal injuries are fractures, dislocations, sprains, and strains. Some injuries may involve more than one type of injury: For example, a direct blow to the knee may injure both ligaments and bones. Broken bone Chipped bone Fracture MUSCULOSKELETAL INJURIES A fracture is a partial or complete break in bone tissue. Fractures include chipped or cracked bones, as well as bones that are broken completely into separate pieces (Figure 10–1). Because bones are made of hard, rigid tissues, any force that causes a bone to bend is likely to result in a fracture. This force could be from a blunt impact, or it could be caused by a movement of the body (e.g., a strong twisting motion). Even a powerful muscular contraction can result in a fracture. 196 Figure 10–1: Fractures include chipped, cracked, or completely broken bones. Fractures are not always easy to recognize without a telltale sign, such as an open wound with protruding bone ends or a severely deformed body part. The mechanism of injury is often the best indicator of whether you should suspect a fracture. Fractures can be classified as open or closed. Dislocation Open fractures involve open wounds. They often occur when an extremity is severely angulated or bent, causing a bone to break and then forcing the tip through the skin and other local soft tissues. Open fractures can also occur when an object, such as a bullet, penetrates the skin and breaks a bone. A dislocation is a displacement or separation of a bone from its normal position at a joint (Figure 10–2). Dislocations are usually caused by powerful forces that push the joint beyond its normal range of motion, such as twisting the joint or falling in an awkward position. Some joints, such as the shoulder, are more prone to dislocation because they are less protected from injury or are exposed to strong forces more often. Others, such as the joints of the spine, are well protected and therefore dislocate less often. Closed fractures leave the skin unbroken. They are more common than open fractures and can be displaced or simple. Open fractures are more serious than closed fractures because of the risks of infection and hemorrhage (although closed fractures may cause internal hemorrhaging). Although fractures are rarely an immediate threat to life, any fracture involving a large bone can cause hypovolemic shock because of the hemorrhaging that can result. When the ends of a bone that meet at a joint are forced far enough beyond their normal position, the ligaments stretch and tear. Once this has happened, subsequent dislocations of the same joint are more likely to occur. Dislocations are generally more obvious than fractures because the joint will be visibly deformed. Often the end of the displaced bone causes an abnormal lump, ridge, or depression beneath the skin. An injured patient will generally be unable to move a joint that is dislocated. A force violent enough to cause a dislocation can also cause a fracture and can damage nearby nerves and blood vessels. Do not attempt to reinsert a dislocated joint, as this can cause additional damage unless your scope of practice or medical director specifies that this is the appropriate intervention. A sprain is the partial or complete stretching or tearing of ligaments at a joint. A sprain usually results when the bones that form a joint are forced beyond their normal range of motion (Figure 10–3). Mild sprains, which only stretch ligament fibres, generally heal quickly. The patient may have only a brief period of pain or discomfort (7 to 10 days) and quickly return to activity with little or no lingering effects. Severe sprains usually cause pain when the joint is moved. A force that results in a severe sprain can also involve a fracture of the bones that form the joint. Often, a sprain is more disabling than a fracture. When fractures heal, they usually leave the bone as strong as it was before; it is unlikely that a repeat break will occur at the same location. Once ligaments have been stretched or torn, however, the joint may become unstable and more vulnerable to reinjury, especially if the initial sprain is not cared for properly. It is important that patients have even minor sprains examined to reduce the risk of lifelong complications. Figure 10–2: A dislocation is a displacement or separation of a bone from its normal position at a joint. range when exercising. They can also result from sudden or uncoordinated movements, such as twisting to avoid falling on a patch of ice. Strains commonly involve the muscles in the neck or back, the thigh, or the back of the lower legs. Strains of the neck and lower back can be particularly painful and disabling. Like sprains, strains are often neglected, which makes them very susceptible to reinjury. Strains sometimes recur chronically, especially those involving the muscles of the neck, lower back, and back of the thigh. These injuries can often be prevented by using proper body mechanics and ergonomics (e.g., proper lifting procedure) for repeated or high-risk tasks. Strain A strain is the stretching and tearing of muscle or tendon fibres. Because tendons are tougher and stronger than muscles, tears usually occur in the muscle itself or where the muscle attaches to the tendon. Strains are often the result of overexertion, such as lifting an object that is too heavy or stretching a muscle beyond its normal Figure 10–3: A sprain usually results when the bones that form a joint are forced beyond their normal range of motion. MUSCULOSKELETAL INJURIES Sprain 197 SPLINTS SOFT SPLINTS A splint is used to immobilize an injured extremity to reduce the risk of additional injury and help reduce pain for the patient. Soft splints include folded blankets, towels, pillows, slings, and triangular bandages (Figure 10–5). A blanket can be used to splint an injured ankle (Figure 10–6). A folded triangular bandage is used to secure dressings or splints in place. Types of Splint There are four general types of splints: 1. Soft 2. Rigid 3. Anatomical 4. Traction As a professional responder, you are likely to have a variety of commercially made splints available. These include padded board splints, air splints, specially designed flexible splints, and vacuum splints (Figure 10–4). You should familiarize yourself with each of the commercial splinting devices at your disposal before using it in the field. RIGID SPLINTS Rigid splints are made of hard, inflexible materials that hold the extremity firmly in one position. Commercial rigid splints include a range of sizes, including longer models for leg injuries and shorter models for injuries to the arms. Some have a moldable aluminum core surrounded by padding: These can be shaped to the affected area to increase support and comfort (Figure 10–7). ANATOMICAL SPLINTS Anatomical splints use the patient’s own body to support an injured part. For example, an arm can be immobilized against the chest, or an injured leg MUSCULOSKELETAL INJURIES Figure 10–5: Soft splints include folded blankets, towels, and triangular bandages. 198 Figure 10–4: Commercial splints. Figure 10–6: A blanket can be used to splint an injured ankle. can be immobilized using the uninjured leg for support (Figure 10–8). TRACTION SPLINTS A traction splint is a special type of splint used primarily to immobilize fractures of the femur. One end attaches to the patient’s hip and the other to the patient’s ankle. When traction is engaged, a constant, steady pull is applied to opposite ends of the leg, stabilizing the fractured bone’s ends and keeping them from causing any further damage to soft tissues in the thigh (Figure 10–9). Each commercial brand of traction splint has its own unique method of application. Refer to the manufacturer’s directions, and only apply traction splints that you are proficient with. Figure 10–7: A rigid splint can be used to support an injured arm. Rule of Thirds Some specific injuries require special splinting considerations. To determine which type of splint is most appropriate for an injury, you should determine whether the injury is a joint injury or mid-shaft injury. This can be difficult with longbone fractures. To determine if an injury is a joint or mid-shaft injury, use the Rule of Thirds. Each long bone (see the section on Bones in Chapter 4) can be divided into thirds. If the injury is located in the upper or lower third of the bone, treat the injury as a joint injury. If the injury is in the middle third of the bone, treat it as a mid-shaft injury. Figure 10–8: An injured leg can be splinted to the uninjured leg. When using a splint, follow these basic principles: Use appropriate equipment. Splint only if it can be done without causing further injury. Immobilize the joints above and below the injury site in the splint. Check for normal circulation and sensation before and after splinting. Familiarize yourself with the manufacturer’s directions before using a commercial splint. Before splinting, cover any open wounds with dressings and bandages to help control bleeding and prevent infection. Figure 10–9: A traction splint is primarily used to immobilize femur fractures. MUSCULOSKELETAL INJURIES How to Splint 199 While applying a splint, support the injured body part to reduce pain and mitigate the risk of additional injuries. If the injury involves an extremity, check for normal sensation in the digits distal to the injury. You should also check distal circulation: Check the patient’s pulse, as well as the colour, temperature, and capillary refill in the digits below the injury. Abnormalities can be identified more easily by comparing the injured extremity against the uninjured one. If you are using a rigid or anatomical splint, pad the splint so that it is shaped to the injured part. Using the uninjured limb as a guide to normal positioning will help prevent further injury and increase comfort for the patient. If using a moldable splint, shape the splint to the uninjured extremity, then transfer it to the injured side. MUSCULOSKELETAL INJURIES To effectively immobilize an injured part, a splint must extend above and below the injury site (Figure 10–10) and include the joints above and below the injury. 200 Secure the splint in place with an elastic roller bandage or the straps provided with the splint. Always move from stable to unstable when attaching a splint: This means first anchoring the splint to strong, uninjured areas, and then wrapping towards the injured part. For example, if a patient has a broken elbow, begin securing the splint at the axilla (armpit) and work distally towards the elbow, stopping short of the injury site. Next, secure the splint from below the wrist, working proximally towards the elbow and again stopping short of the injury. Finally, carefully wrap the injured area with a separate elastic roller bandage. This last bandage can then be removed to allow an examination of the injury without compromising the stability of the splint. Recheck circulation and sensation below the injury to ensure that they have not been restricted due to the pressure from the splint. If either circulation or sensation has changed, loosen the splint slightly and reassess. You should also loosen the splint if the patient complains of numbness or if the fingers or toes turn blue or become cold. If there are signs of pooling fluids, loosen the bandages. Figure 10–10: To effectively immobilize an injured part, a splint must extend above and below the injury site. After a musculoskeletal injury has been immobilized, recheck the patient’s ABCs and vital signs, and take steps to care for shock. Shock is likely to develop as a result of a serious musculoskeletal injury. Help the patient rest in the most comfortable position, apply ice or a cold pack to the injured area, maintain normal body temperature, and offer reassurance to the patient. With the patient’s willingness, a single attempt may be made to straighten a fractured limb if more advanced medical care is not available within 30 minutes and the patient is exhibiting signs of the following: A decrease or absence of distal circulation, sensation, and/or mobility Gross angulation of the limb Tenting of the skin Severe pain Do not attempt this if you suspect a joint injury, such as a dislocation, or if you observe firm resistance to movement, a significant increase in pain, or the sound or feeling of bone fragments grating. SLINGS A sling is used to support an upper extremity if a musculoskeletal injury damages the usual support structures. For example, a patient with a dislocated right shoulder will require a sling to support his or her right arm. Commercial slings are available, and slings may also be improvised using a triangular bandage (Figure 10–11). A sling may also be applied to a splinted arm to provide additional support. Figure 10–11: A triangular bandage can be used to create a sling. SIGNS AND SYMPTOMS OF MUSCULOSKELETAL INJURIES Five common signs and symptoms of musculoskeletal injuries are: 1. Pain. 2. Swelling. 3. Deformity. 4. Discoloration of the skin. 5. Inability to use the affected part normally. Irritation and damage to nerve endings in the injured area cause pain. The injured area may be painful when touched, when moved, or both. Swelling is often caused by bleeding from damaged blood vessels in the injured area. Swelling may also occur due to excessive fluid production by the synovial capsule surrounding the joint. This swelling may appear rapidly at the MUSCULOSKELETAL INJURIES Using gentle traction, straighten the limb into anatomical position. Grasp the limb above and below the site of injury and pull gently. Reassess circulation and sensation below the injury once you have realigned the limb. If either is still impaired, the patient should be in the rapid transport category. 201 site of injury, develop gradually, or not appear at all. Therefore, swelling alone may not be a reliable indicator of which structures are involved or of the severity of an injury. Internal bleeding may discolour the skin in surrounding tissues, but it may take hours or days to appear. At first, the skin may only look red. As blood seeps to the skin’s surface, however, contusions will usually appear. Deformity may also be a significant sign of injury (Figure 10–12). Abnormal lumps, ridges, depressions, or unusual bends or angles in body parts are examples of deformities that can indicate a musculoskeletal injury. Comparing the injured part with the corresponding part on the uninjured side can help you identify abnormalities. An injured patient’s inability or unwillingness to move or use an injured part may also indicate a significant injury. The patient may tell you that he or she is unable to move it or that it is simply too painful to move. Moving or using injured parts can disturb tissues and further irritate nerve endings, which causes or increases pain. Often, the muscles of an affected area will spasm in an attempt to keep the injured part from moving. An injured patient will usually support an injured part in the most comfortable position. To care for musculoskeletal injuries, try to avoid causing patients additional pain: Don’t move an injured part unless it is necessary for assessment or interventions. Figure 10–12: Deformity may be a sign of significant injury. Other signs and symptoms that suggest a fracture include: A significant deformity. A snapping or popping sound at the moment of injury. A mechanism of injury that suggests the trauma may be severe. Crepitus. Moderate to severe swelling and/or discoloration. An inability to move or use the affected body part. Visible broken bones protruding from the skin. Loss of circulation or sensation in an extremity. MUSCULOSKELETAL INJURIES Sprains and strains are fairly easy to differentiate based on where the signs of injury are located. Because a sprain involves the soft tissues at a joint, any pain, swelling, and deformity are usually confined to the joint area. Strains involve the soft tissue structures that, for the most part, lie between joints (Figure 10–13). 202 The most serious musculoskeletal injuries are fractures, as they are most likely to cause additional damage to internal structures or result in permanent impairment without prompt treatment. If a bone is fractured, you may detect crepitus, which is a grating, popping, or crackling sound or sensation beneath the skin in the injured area. It can have multiple causes but is commonly caused by fractured pieces of bone rubbing against one another. Figure 10–13: Strains generally involve an area between the joints. CARE FOR MUSCULOSKELETAL INJURIES Musculoskeletal injuries are rarely life-threatening, unless other tissues are damaged as well, but the patient should be examined by a physician to reduce the risk of complications. General Care While it can be difficult to identify the exact nature of a musculoskeletal injury in the field, the general care for all musculoskeletal injuries is similar (Figure 10–14). Performing a focused assessment on the injured area will help you to determine the nature of the injury. If the injury involves more than minor bleeding, apply direct pressure until the bleeding stops (as described in Chapter 9). Movement of a fractured bone can cause additional tissue damage: Avoid putting more pressure on the injured area than is necessary to control the bleeding. Remember the acronym RICE: R — Rest I — Immobilize C — Cold E — Elevate REST Avoid any unnecessary actions that cause the patient pain. Help the patient find the most comfortable position. If you suspect a head and/or spinal injury, leave the patient lying flat. Do not move the patient unless it is absolutely necessary. Figure 10–14: General care for all musculoskeletal injuries is similar—rest, immobilize, cold, elevate (RICE). IMMOBILIZE If you suspect a serious musculoskeletal injury, you must immobilize the injured part before giving additional care, such as applying ice or elevating the injury. To immobilize, apply a splint, sling, or bandages (or use another appropriate method) to reduce movement of the injured part. The purpose of immobilizing an injury is to: Reduce pain. Reduce the risk of a hemorrhage. Reduce potential loss of circulation to the injured part. Prevent further damage to soft tissues. Prevent closed fractures from becoming open fractures. If possible, always splint a musculoskeletal injury before moving the patient. Fractures of large bones especially can cause internal hemorrhaging, which may lead to shock. COLD If the injury is not an open wound (i.e., if it is a closed fracture, dislocation, sprain, or strain), apply ice or a cold pack. Cold helps ease pain and discomfort. Place a thin layer of gauze or cloth between the source of cold and the skin to prevent skin damage. Do not apply an ice or cold pack directly over a fracture because the pressure could cause discomfort to the patient. Instead, place cold packs around the site of injury. In general, cold should be applied for 15 to 20 minutes every hour for the first 24 to 48 hours (as needed) after an injury. MUSCULOSKELETAL INJURIES However, a patient in the following situations requires rapid transport: The injury involves a hemorrhage. The injury involves trauma to the skull or spine. The injury impairs the patient’s respiration. There is severe angulation with reduction in or loss of sensation and/or circulation. There are multiple major musculoskeletal injuries suspected (e.g., two long-bone fractures). 203 FRONT VIEW Clavicle ELEVATE Elevating the injured area above the level of the heart helps to reduce swelling. Always immobilize a seriously injured limb before elevating. Do not elevate an injured area if doing so causes the patient additional pain, as this may aggravate the injury. Humerus Ulna Radius UPPER EXTREMITY INJURIES The upper extremities are the arms and hands. Upper extremity bones include the clavicle, scapula, humerus, radius and ulna, carpals and metacarpals, and phalanges. Figure 10–15 shows the major structures of the upper extremities. The upper extremities are the most commonly injured area of the body. Injuries to the upper extremities occur in many different ways. The most frequent cause is falling on the hand of an outstretched arm. Since the hands are rarely protected, abrasions occur easily. A falling person instinctively tries to break the fall by extending the arms and hands, so these areas receive the force of the body’s weight. This can cause a severe sprain, fracture, or dislocation to the hand, forearm, upper arm, or shoulder (Figure 10–16). Carpals Metacarpals Phalanges BACK VIEW Scapula Humerus Ulna Radius Carpals Metacarpals MUSCULOSKELETAL INJURIES When caring for serious upper extremity injuries, minimize any movement of the injured area. If a patient is holding the arm securely against the chest, do not attempt to change the position. Holding the arm against the chest is an effective method of immobilization because it keeps an injured body part from moving. Allow the patient to continue to support the arm in this manner. You can further assist the patient by binding the injured arm to the chest. This eliminates the need for special splinting equipment and still provides an effective method of immobilization. 204 Injuries to the upper extremities may also damage blood vessels, nerves, and several soft tissues. It is particularly important to ensure that blood flow and nerve function have not been impaired. Always check the peripheral pulse and ensure that sensation below the injury site is normal both before and after splinting. Sometimes, when a splint is applied too tightly, circulation may be Phalanges FRONT VIEW Median nerve Brachial artery Ulnar nerve Radial nerve Radial artery Figure 10–15: The major structures of the upper extremities. Scapular fractures are not common. You are less likely to see deformity of the scapula: The most significant signs and symptoms are extreme pain and the inability to move the arm. It takes a great deal of force to break the scapula, so an MOI that results in a fractured scapula is likely to injure the ribs or internal organs in the chest as well. This is often indicated by dyspnea. impaired. If this occurs, loosen the splint. If you suspect that either the blood vessels or the nerves have been damaged, minimize movement of the area and obtain more advanced medical care immediately. Shoulder Injuries The shoulder consists of three bones that meet to form the shoulder joint: the clavicle, the scapula, and the humerus. The most common shoulder injuries are sprains. However, injuries of the shoulder may also involve a fracture of one or more of these bones or a dislocation of the shoulder joint. The most frequently injured bone of the shoulder is the clavicle, though this is more common in children than adults. Typically, the clavicle is fractured as a result of a fall. The patient usually reports pain in the shoulder area that may radiate down the arm. A patient with a fractured clavicle usually attempts to ease the pain by holding the arm against the chest. Since the clavicle lies directly over major blood vessels and nerves, it is important to immobilize the injured area to prevent injury to these structures. SPECIFIC CARE FOR SHOULDER INJURIES Follow the general care steps for musculoskeletal injuries. Support the joint by applying an elastic roller bandage in a figure-eight pattern around the shoulder. Help the patient to keep the injured arm in the position that he or she is naturally holding it in. If the patient is holding the arm away from the body, for example, place a soft object such as a pillow or folded blanket between the arm and the torso to provide support. Immobilize the injured arm by binding it to the chest or by placing the arm in a sling and then binding it to the chest with a triangular bandage folded into a broad bandage (Figure 10–17, a-c). MUSCULOSKELETAL INJURIES Figure 10–16: A fall can cause a serious injury to the hand, arm, or shoulder. A dislocation is another common type of shoulder injury. Like fractures, dislocations often result from falls. This happens frequently in contact sports, such as football and rugby. A player may attempt to break a fall with an outstretched arm or may land on the tip of the shoulder, forcing the arm against the joint formed by the scapula and clavicle (this is commonly referred to as a separation). This can result in ligaments tearing, causing the end of the clavicle to displace. Dislocations also occur at the joint where the humerus meets the socket formed by the scapula. For example, when a patient’s arm is struck while raised in the throwing position, the arm is forced to rotate backward, tearing ligaments and causing the upper end of the arm to dislocate from its normal position in the shoulder socket. Shoulder dislocations are painful and can often be identified by the deformity present. As with other shoulder injuries, the person often tries to minimize the pain by holding the arm in the most comfortable position. 205 a b c Figure 10–17, a-c: Splint the arm against the chest in the position the patient was holding it. Upper Arm Injuries The humerus is a long bone that can be fractured at any point, although fractures most often occur near the shoulder or in the middle of the bone. The upper third of the humerus fractures more often in older adults and young children, often as a result of falls. Fractures in the middle third occur mostly in young adults. A fractured humerus can cause damage to the blood vessels and nerves supplying the entire arm. Most humerus fractures are very painful and prevent the person from using the arm. These fractures can cause considerable deformity. MUSCULOSKELETAL INJURIES SPECIFIC CARE FOR UPPER ARM INJURIES 206 and blood vessels of the forearm and hand pass through the elbow, injuries to the elbow can cause permanent disability. Like all joint injuries, elbow injuries can be made worse by movement. Use caution when assessing an injured elbow to reduce the risk of causing further damage. SPECIFIC CARE FOR ELBOW INJURIES Follow the general care steps for musculoskeletal injuries. If the patient indicates an inability to move the elbow, do not try to move it. Support the arm and immobilize it in the position found with a long moldable splint from the axilla to the hand (including the fingers) (Figure 10–18). Once the arm is immobilized, and if the angle of the elbow allows it, place the arm in a sling and secure it to the chest. Follow the general care steps for musculoskeletal injuries. If you suspect a fracture, apply a moldable long splint from the axilla to the wrist to prevent movement of the elbow, immobilizing the upper arm in the position found. If a fracture is not suspected (or if the position of the splinted arm allows it), place the arm in a sling. If necessary, provide additional support by binding the forearm to the chest with triangular bandages (so long as this doesn’t cause discomfort or risk aggravating the injury). Elbow Injuries Like other joints, the elbow can be sprained, fractured, or dislocated. Since all the nerves Figure 10–18: Immobilize the arm from shoulder to wrist, keeping the elbow in the position found. Forearm, Wrist, and Hand Injuries The forearm is the part of the upper extremity extending from the elbow to the wrist. Fractures of the two forearm bones, the radius and ulna, are most common in children and older adults. If a person falls on the palmar surface of an outstretched arm, both bones of the lower arm may break, but not always in the same place. A fracture of both bones can cause the arm to appear S-shaped (Figure 10–19). Because the radial artery and nerve are near these bones, a fracture may cause a hemorrhage or a loss of movement in the wrist and hand. Sprains of the wrist are also common. The hands are very susceptible to injury because they are used so often in daily activities. SPECIFIC CARE FOR FOREARM, WRIST, AND HAND INJURIES Figure 10–19: Fractures of both bones of the forearm may lead to an S-shaped deformity. Follow the general care for musculoskeletal injuries. If a single finger is damaged, it can be immobilized by taping it to the adjacent finger (Figure 10–20). You can also place a tongue depressor (padded with gauze) along the underside of the finger and immobilize it with tape. Figure 10–20: An injured finger can be splinted to an adjacent finger. Care for an injured forearm or wrist by immobilizing the injured area. Place a splint underneath the forearm. When using a rigid splint, extend the splint beyond the hand, and immobilize the elbow by splinting to the shoulder. Place a roll of gauze or a similar object in the palm to keep the palm and fingers in a position of function. Place the arm in a sling and secure it to the patient’s chest (Figure 10–22). MUSCULOSKELETAL INJURIES If multiple fingers or the hand itself are damaged, you should attempt to immobilize them in a position of function. This is the natural, gentle curve of the fingers and palm when at rest. If the fingers are bleeding, place gauze between them. If the hand is bleeding, wrap it in gauze. Next, splint the patient’s forearm from the elbow to just beyond the fingertips. Beginning at the elbow, attach the splint firmly to the forearm with a roller bandage, avoiding excessive pressure. A moldable splint is best suited. Leave a gap in the bandage that will allow you to assess the radial pulse. When you reach the hand, place a roll of non-sterile gauze in the patient’s palm to increase comfort and maintain the position of function (Figure 10–21, a-b), then wrap the hand with a roller bandage. Once it is immobilized, support the injured hand with a sling and secure it to the patient’s chest. 207 a b Figure 10–21, a-b: A roll of gauze can be used to immobilize a hand: a, start wrapping at the wrist; b, cover the hand with a roller bandage. MUSCULOSKELETAL INJURIES Figure 10–22: If the forearm is fractured, place a splint under the forearm and secure it. 208 LOWER EXTREMITY INJURIES Injuries to lower extremities can involve both soft tissue and musculoskeletal trauma. The major bones of the thigh and lower leg are large and strong because they carry the body’s weight. Bones of the leg include the femur, patella, tibia, and fibula, as well as the tarsals, metatarsals, and phalanges. Because of the size and strength of the bones in the thigh and lower leg, a significant amount of force is required to cause a fracture. Serious injuries to the lower extremities can result in their inability to bear weight. bone ends together, causing them to overlap. This may cause the injured leg to be noticeably shorter than the other leg. The injured leg may also be turned outward (Figure 10–24). Other signs and symptoms of a fractured femur may include severe pain and swelling and the inability to move the leg. Pelvis The femoral artery is the major supplier of blood to the legs and feet. If it is damaged, as may happen with a fracture of the femur, the blood loss can be rapidly life-threatening. A weak or absent pulse distal to the injury is a sign of damage to the femoral artery. Hip SPECIFIC CARE FOR THIGH INJURIES Figure 10–23: The upper end of the femur meets the pelvis at the hip joint. Thigh Injuries The femurs are the largest bones in the body and are the most important for walking and running. The upper end of the femur meets the pelvis at the hip joint (Figure 10–23). Most femur fractures involve the upper end of the bone. Even though the hip joint itself is not usually involved, these injuries are often referred to as hip fractures. A fracture of the femur usually produces a characteristic deformity. When a fracture occurs, the thigh muscles begin to contract. The thigh muscles are so strong that they can pull the broken Follow the general care for musculoskeletal injuries. If the upper or lower third of the femur is fractured, treat the injury as a joint injury (hip or knee). Because of the risk of an internal hemorrhage, a patient with a fractured femur should always be placed in the rapid transport category. Control any external bleeding before immobilizing the injured area (Figure 10–25). Keep the patient in the most comfortable position. If a patient’s femur is broken, apply a long rigid splint from the axilla (armpit) to the foot on the lateral side, and a second rigid splint on the medial side from the groin to the bottom of the foot (or just beyond). Traction splints may be indicated for fractures of the femur (as dictated by your scope of practice and local protocols). Figure 10–26, a-b, shows two types of traction splints. Figure 10–24: A fractured femur often produces a characteristic deformity. The injured leg is shorter than the uninjured leg and may be turned outward. MUSCULOSKELETAL INJURIES Femur 209 Figure 10–25: It is important to stop any external bleeding before immobilizing the injured area. Another method involves securing the injured leg to the uninjured leg (i.e., creating an anatomical splint). This should only be used if the patient is in a rapid transport situation, when speed is crucial. Roll a blanket so that it fills the space from groin to ankle without putting unnecessary pressure on the injured area. Measure the blanket against the outside of the uninjured leg before placing it between the legs. Bring the uninjured leg to the injured leg, and bind the legs together in several places above and below the site of the injury using wide elastic straps or broad bandages (Figure 10–27). Ensure that there is sufficient padding between the legs to maximize comfort for the patient and reduce the risk of injury. If the patient is not on a rigid device such as a backboard, ensure that the knees are supported from behind so they will not bend when the patient is moved. Lower Leg Injuries MUSCULOSKELETAL INJURIES a 210 b Figure 10–26, a-b: Two types of traction splints. A fracture in the lower leg may involve one or both bones (fibula and tibia). Like the bones in the forearm, they are often fractured simultaneously. However, a blow to the outside of the lower leg can cause an isolated fracture of the fibula. Open fractures are common because the fibula and tibia lie just beneath the skin. A lower leg fracture may cause a severe deformity in which the lower leg is bent at an unusual angle (angulated). These injuries are painful and result in an inability to move the leg. However, fractures of the fibula, and small fractures of the tibia, may not cause any deformity, and the patient may even be able to use the leg. Figure 10–27: To splint an injured leg, secure the injured leg to the uninjured leg with triangular bandages. A rolled blanket between the legs provides support and comfort. SPECIFIC CARE FOR LOWER LEG INJURIES Follow the general care for musculoskeletal injuries. If the upper or lower third of the tibia or fibula is fractured, treat the injury as a joint injury (knee or ankle). If the tibia or fibula is fractured, apply a rigid long splint to the lateral side of the injured leg, extending from just below the hip to below the foot. Place a shorter padded splint on the medial side of the leg, extending from the groin to the foot (Figure 10–28). Specific commercial splints, such as air splints and vacuum splints, are available for these applications. Knee Injuries The knee joint includes the lower end of the femur, the upper ends of the tibia and fibula, and the patella (kneecap). This joint is very vulnerable to injury. The patella is a bone that moves on the lower front surface of the thigh bone. Sprains, fractures, and dislocations of the knee are common in athletic activities that involve quick movements or exert unusual force on the knees. The knee joins the two longest bones of the body, the femur and the tibia. Four ligaments attach to the bones and hold the knee together. Two cartilage discs serve to increase joint stability, facilitate joint lubrication, and absorb shock. This cartilage can be torn due to a torsion injury. Repeated and excessive shocks to the knee can also splinter the cartilage pads and stretch or fray the ligaments. Figure 10–28: Rigid splints can also be used to splint an injured leg. on the lateral side, and from the foot to the groin on the medial side (as you would for an injury of the thigh). Ankle and Foot Injuries Ankle and foot injuries are commonly caused by twisting forces. Injuries range from minor sprains with little swelling and pain to fractures and dislocations. As with other joint injuries, you cannot always distinguish between minor and severe injuries. You should initially care for any ankle or foot injury as if it is serious. As with other lower extremity injuries, a physician should evaluate an ankle or foot injury if it appears swollen, is unable to bear weight, or causes pain when moved. Fractures are possible when any great force is applied, such as falling from a height and landing on the feet. The force of the impact may also be SPECIFIC CARE FOR KNEE INJURIES Follow the general care for musculoskeletal injuries. For a soft tissue injury, such as a sprain, apply an elastic roller bandage using a figure-eight pattern. In the case of a fracture, splint the knee in the position found. If the knee is bent, support it in the bent position (Figure 10–29). If the knee is straight, splint the leg from the foot to the axilla Figure 10–29: Support a knee injury in the bent position if the patient cannot straighten the knee. MUSCULOSKELETAL INJURIES The kneecap is unprotected in that it lies directly beneath the skin. This part of the knee is very vulnerable to bruises and lacerations, as well as dislocations. Any violent trauma to the front of the knee can cause fractures of the patella. 211 transmitted up the legs. This can result in an injury elsewhere in the body, such as the thigh, pelvis, or spine. If the MOI suggests that these serious injuries may be present, take necessary precautions (e.g., spinal motion restriction). Foot injuries may also involve the toes. Although these injuries are painful, they are rarely serious. SPECIFIC CARE FOR ANKLE AND FOOT INJURIES MUSCULOSKELETAL INJURIES Follow the general care for musculoskeletal injuries. If the ankle is injured, immobilize it in the position found. This can be done with a commercial splint or a pillow splint. The improvised splint is made by placing the ankle in the centre of a pillow and folding the sides of 212 the pillow around the ankle. Secure the pillow to the ankle with elastic straps or broad bandages. You may also immobilize an injured ankle with two well-padded rigid splints, one lateral and one medial, extending from above the knee to the foot. A pillow splint (described above) is generally effective for most foot injuries as well. If the injury was caused by crushing forces to the toes (tarsals), place gauze between the toes before splinting to absorb fluid and prevent the toes from adhering to one another. SUMMARY TYPES OF MUSCULOSKELETAL INJURIES TYPES OF SPLINTS Fracture A partial or complete break in bone tissue Open fractures: damaged bone breaks through the skin Closed fractures: bone is damaged but it does not break through the skin Soft Found materials that are soft and flexible (e.g., blankets, slings, pillows) Rigid Improvised or commercial splints made of hard, inflexible materials Anatomical Use the patient’s own body to support an injured part Dislocation Displacement or separation of a bone from its normal position at a joint Can cause torn or stretched ligaments Traction Used to immobilize femur fractures Sprain Partial or complete stretching or tearing of ligaments and other tissues at a joint Mild sprains: only ligament fibres stretch; heal quickly; minor pain Severe sprains: cause pain when injury occurs; more likely to involve a fracture Susceptible to reinjury Strain Stretching and tearing of muscle or tendon fibres Susceptible to reinjury Common Signs and Symptoms of Musculoskeletal Injuries Use appropriate equipment. Do not cause further injury. Ensure splint includes joints  above and below the injury site. Check for normal circulation and sensation before and after splinting. Follow the manufacturer’s  directions for commercial  splints. Pain Swelling Deformity Discolouration of the skin Inability to use the affected part normally General Care for Musculoskeletal Injuries R – Rest I – Immobilize C – Cold E – Elevate MUSCULOSKELETAL INJURIES Basic Splinting Principles 213