I



Detailed Lesson Plan

Chapter 30

Musculoskeletal Trauma

120–130 minutes

|Chapter 30 objectives can be found in an accompanying folder. |

|These objectives, which form the basis of each chapter, were developed from the new Education Standards and Instructional Guidelines. |

|Minutes |Content Outline |Master Teaching Notes |

| |Introduction |Case Study Discussion |

|5 |During this lesson, students will learn to assess and treat a painful, swollen, or deformed extremity. |What are the patient management priorities in such a |

| |Case Study |situation? |

| |Present Dispatch and Upon Arrival information from the chapter. |Describe how you will proceed with this patient. |

| |Discuss with students how they would proceed. | |

| |Musculoskeletal System Review—The Muscles |Teaching Tip |

|10 |Voluntary (skeletal) muscles are under control of a person’s will. |Since this section is review material, rely more heavily on |

| |Voluntary muscles make possible all deliberate acts such as walking, chewing, and frowning. |questioning students rather than providing information. |

| |Most voluntary muscles are attached to the skeleton at one or both ends. | |

| |Voluntary muscles form the major muscle mass of the body. |Knowledge Application |

| |Muscle tissue contracts when stimulated by a nerve impulse. |Students should be able to use the information in this section|

| |Muscles give our bodies their distinctive shapes. |to assess and describe musculoskeletal injuries. |

| |Muscles can be injured in many ways. | |

| |Broken fibers from overextension |Discussion Question |

| |Bruises |What happens to the shape of the muscles when they contract? |

| |Crushing | |

| |Cuts | |

| |Tears | |

| |Painful swelling and weakness | |

| | | |

| | | |

| |Musculoskeletal System Review—Tendons and Ligaments | |

|5 |The “glue” that holds the body together | |

| |Composed of specialized connective tissue | |

| |Tendons connect muscle to bone. | |

| |Ligaments connect bone to bone. | |

| |Can be bruised, crushed, cut, or torn | |

| |Musculoskeletal System Review—Cartilage |Discussion Question |

|5 |Extension of the bone |What is the function of cartilage? |

| |Comprised of connective tissue | |

| |Strong, smooth, flexible, compressible, slippery substance | |

| |Found at the point of articulation of two bones | |

| |Protects bones in motion from friction | |

| |Acts as shock absorber between bone surfaces | |

| |Leads to joint pain when injured | |

| |Musculoskeletal System Review—The Skeletal System |Discussion Questions |

|10 |Upper extremity (shoulder girdle, arm, forearm, hand) |What are the components of the appendicular skeleton? |

| |Clavicle (collar bone) |Where is the greater trochanter of the femur? |

| |Scapula (shoulder blade) | |

| |Humerus (upper arm bone) |Class Activity |

| |Radius (lower arm bone) |Assign groups of students to prepare presentations to review |

| |Ulna (including the olecranon) (lower arm bone and elbow) |the musculoskeletal system. Divide the following topics among |

| |Carpal bones (wrist bones) |the groups: Skeletal Muscle, Axial Skeleton, Shoulder Girdle |

| |Metacarpals (hand bones) |and Upper Extremities, Pelvis and Lower Extremities, and Types|

| |Phalanges (finger bones) |of Joint Movements. Give students 20 minutes to prepare before|

| |Lower extremity (pelvis, thigh, leg, foot) |reporting back to the class. |

| |Pelvis (including the ilium, ischium, and pubis) | |

| |Femur (thigh bone) | |

| |Patella (kneecap) | |

| |Tibia (lower leg bone) | |

| |Fibula (lower leg bone) | |

| |Calcaneus (heel bone) | |

| |Tarsals (ankle bones) | |

| |Metatarsals (foot bones) | |

| |Phalanges (toe bones) | |

| |Injuries to Bones and Joints—Types of Injuries |Teaching Tip |

|15 |Fracture |Obtain and show a variety of radiographs of orthopedic |

| |A break in the continuity of a bone |injuries. |

| |Caused by direct force, indirect force, or twisting force | |

| |Open fracture—Associated with an open wound |Discussion Questions |

| |Closed fracture—Skin is not broken. |Which joints are most commonly dislocated? |

| |Type can only be distinguished by X-ray. |Why should you consider dislocations significant injuries? |

| |Hairline fracture—Small crack in bone, does not create instability | |

| |Pathologic fracture—Result of degenerative disease such as osteoperosis |Knowledge Application |

| |Can result in various complications |Students should be able to recognize a painful, swollen, |

| |Hemorrhage from the bone |deformed extremity as well as other indications of |

| |Instability of the extremity |musculoskeletal injury. |

| |Surrounding tissue damage | |

| |Infection (open fracture) |Weblinks |

| |Interruption of distal blood supply |Go to and click on the mykit link for |

| |Strain |Prehospital Emergency Care, 9th edition to access web |

| |Injury to a muscle or tendon |resources on osteoperosis, fractures (including images), |

| |Often due to overextension (overstretching) |growth plate injuries, and additional fracture information |

| |Can be caused by extreme muscle stress or fatigue associated with overuse |from the Journal of the American Medical Association. |

| |No edema or discoloration | |

| |Pain or weakness with use of the muscle | |

| |Sprain |Video Clip |

| |Injury to a joint capsule |Go to and click on the mykit link for |

| |Damage to or tearing of the connective tissue |Prehospital Emergency Care, 9th edition to access a video on |

| |Usually involves ligaments |joint injuries. |

| |Usually occurs in shoulder, knee, or ankle | |

| |Immediate pain and tenderness, followed by inflammation and swelling | |

| |Dislocation | |

| |Displacement of bone from normal position in joint | |

| |Caused by joint being forced beyond normal range of motion | |

| |Obvious deformity and swelling; pain and tenderness | |

| |May occur at shoulder, elbow, wrist, hand, hip, knee, ankle, or foot | |

| |General injury considerations | |

| |Similar signs and symptoms: swelling, pain, or deformity | |

| |Usually associated with external forces (falls, vehicle collisions) | |

| |May occur through degenerative disease, particularly in elderly patients | |

| |Force may cause injuries to surrounding soft tissues and other body areas | |

| |Injuries to Bones and Joints—Mechanism of Injury |Discussion Questions |

|3 |Direct force—Injury occurs at the point of impact. |What is an example of direct force applied to a bone? |

| |Indirect force—Force impacts on one end of a limb, causing injury some distance away from point of impact. |What is an example of indirect force applied to a bone? |

| |Twisting force—One part of extremity remains stationary while the rest twists. | |

| | |Weblink |

| | |Go to and click on the mykit link for |

| | |Prehospital Emergency Care, 9th edition to access a web |

| | |resource on tennis elbow. |

| | | |

| | Injuries to Bones and Joints—Critical Fractures: The Femur and the Pelvis | |

|5 |Femur | |

| |Symptoms | |

| |Bone itself bleeds heavily—Up to 1.5 liters of blood | |

| |Tension on thigh muscles is lost so thigh diameter increases, allowing more blood to be housed within thigh. | |

| |Goals of treatment | |

| |Immobilize bone ends. | |

| |Reduce bleeding. | |

| |Effect of traction splint | |

| |Bone ends are realigned, preventing further injury and reducing pain. | |

| |Diameter of thigh is decreased, allowing less blood to accumulate. | |

| |Pelvis | |

| |Bone itself bleeds heavily—Up to two liters of blood | |

| |Application of Pneumatic Antishock Garment (PASG) will stabilize fracture and may help tamponade bleeding pelvis. | |

| |IX. Injuries to Bones and joints—Assessment-Based Approach: Bone or Joint Injuries |Class Activity |

|20 |Scene size-up and primary assessment |Divide the class into small groups to practice assessment of |

| |Take appropriate Standard Precautions. |musculoskeletal injuries. |

| |Consider the mechanism of injury. | |

| |Ask bystanders what caused the injury. | |

| |Try to imagine the forces to which the patient’s body was subjected. | |

| |Check for obvious signs of severe hemorrhage. |Critical Thinking Discussion |

| |Look for signs of shock and treat. |How can you balance the need for immediate transport of a |

| |If the injury has caused a life-threatening condition, immobilize injured extremity and transport immediately |patient in shock with the need to immobilize major fractures |

| |following secondary assessment. |to prevent further bleeding, tissue damage, and pain? |

| |Secondary assessment | |

| |If the patient has a life-threatening condition not directly related to the injury, initiate transport and | |

| |immobilize injury en route if time and patient’s condition permits. | |

| |If the patient is responsive and oriented, inspect and gently palpate bone or joint. | |

| |Be gentle and reassuring. | |

| |Check injury site for signs and symptoms of injury (deformity, contusions, tenderness, and so on). | |

| |Assess baseline vitals and obtain a history from the patient. | |

| |Evaluate the six “Ps.” | |

| |Pain | |

| |Pallor | |

| |Paralysis—May indicate nerve, muscle, tendon, or ligament damage | |

| |Paresthesia (numbness, prickly feeling, or tingling)—May indicate nerve damage | |

| |Pressure—May indicate damaged tissue or internal blood loss | |

| |Pulse—Decrease to or absence of distal pulse may indicate arterial damage. | |

| |Emergency medical care | |

| |If injury threatens patient’s life, immobilize injured extremity during primary assessment or secondary assessment | |

| |if the appropriate resources are available and it does not cause a delay in transport. | |

| |If the patient has other life-threatening conditions, initiate transport and immobilize injured extremity en route | |

| |if time and patient’s condition permits. | |

| |Immobilize the suspected fracture. | |

| |Use proper Standard Precautions. | |

| |Administer oxygen if needed. | |

| |Maintain in-line spine stabilization if spine injury is suspected. | |

| |Splint bone and joint injuries. | |

| |Apply cold packs to painful, swollen, or deformed extremity. | |

| |Elevate the extremity (if spine injury is not suspected). | |

| |Transport. | |

| |Reassessment | |

| |Recheck patient’s vital signs and interventions. | |

| |Make certain injured extremity is properly immobilized. | |

| |Make sure immobilization has not adversely affected patient’s distal pulses, motor function, or sensation. | |

| | Injuries to Bones and Joints—Summary: Assessment and Care | |

|2 |Review possible assessment findings and emergency care for musculoskeletal injuries. | |

| |Review Figures 30-15 and 30-16. | |

| | | |

| |Basics of Splinting—General Rules of Splinting |Discussion Question |

|5 |Before and after applying the splint, assess pulse, motor function, and sensation distal to the injury. |What are the general rules of splinting? |

| |Immobilize joints above and below a long bone injury. | |

| |Remove or cut away clothing and jewelry around the injury site. |Knowledge Application |

| |Cover all wounds with sterile dressings and gently bandage before splinting. |Given a series of scenarios, students should be able to assess|

| |If there is severe deformity or the distal extremity is cyanotic (bluish) or lacks pulses, align injured limb with |musculoskeletal injuries, assign injuries proper priority in |

| |gentle manual traction before splinting. |the overall management of the patient, and demonstrate proper |

| |Never intentionally replace protruding bones or push them back below the skin. |splinting techniques. |

| |Pad each splint to prevent pressure and discomfort. | |

| |Apply the splint before trying to move the patient. |Video Clip |

| |When in doubt, splint the injury. |Go to and click on the mykit link for |

| |If the patient shows signs of shock, do not apply a splint first; align him in the normal anatomical position, |Prehospital Emergency Care, 9th edition to access a video |

| |treat for shock, and transport immediately. |about long bone injuries and splints. |

| | | |

| |Basics of Splinting—Splinting Equipment |Teaching Tips |

|10 |Rigid splints |Show examples of each type of splint as you talk about it. |

| |Commercially manufactured |Provide students with adequate time to practice splinting |

| |Made of wood, wood fiber, plastic, or cardboard |under supervision. |

| |Designed to fit specific limbs, or can be molded to fit any appendage | |

| |May come with washable pads |Discussion Question |

| |Pressure (air or pneumatic) splints |What are some advantages and disadvantages of rigid splints? |

| |Soft and pliable before inflation; rigid once applied and inflated | |

| |Cannot be sized | |

| |May impair circulation | |

| |May interfere with ability to assess pulses |Video Clip |

| |May lose or gain pressure with changes in temperature/altitude |Go to and click on the mykit link for |

| |Seek medical direction regarding use |Prehospital Emergency Care, 9th edition to access a video on |

| |Traction splints |the application of a Sager splint. |

| |Provide a counterpull that alleviates pain, reduces blood loss, and minimizes further injury | |

| |Purpose is to immobilize bone ends, reduce diameter of thigh, and prevent further injury. | |

| |Many types available | |

| |Formable splints | |

| |Rigid but made to be shaped to fit deformed extremity | |

| |Can be fixed in place with cravats or Velcro | |

| |Typically comprised of wire, aluminum, or other flexible metal | |

| |Vacuum splints | |

| |Soft and pliable | |

| |Easily formed to deformed extremities | |

| |When air is sucked out, splint becomes extremely rigid. | |

| |Sling and swathe | |

| |Provides stability to injured shoulder, elbow, or upper humerus | |

| |Sling supports arm; swathe holds arm against chest. | |

| |Minimizes pain and further injury | |

| |Spine board | |

| |Considered a full body splint | |

| |Use in cases of critical injury to provide stability where extremity fractures cannot be splinted at scene. | |

| |Improvised splints |Class Activity |

| |Light in weight but firm and rigid |Have a contest to see which group of students can come up with|

| |As wide as thickest part of fractured limb |the best improvised splint. |

| |Long enough to extend past joints and prevent movement | |

| |Padded well so inner surfaces are not in contact with skin | |

| |Possible materials include cane, cardboard, umbrella, pillow, and so on. | |

| |Basics of Splinting—Hazards of Improper Splinting | |

|5 |Compression of nerves, tissues, and blood vessels | |

| |Delay in patient’s transport | |

| |Reduction of distal circulation | |

| |Aggravation of bone or joint injury | |

| |Aggravation or cause of damage to tissue, nerves, blood vessels, or muscles | |

| |Basics of Splinting—Splinting Long Bone Injuries | |

|5 |Look for exposed bone ends, joints locked in position, paresthesia (tingling), paralysis, and pallor. | |

| |Assess the pulse and motor and sensory function below the injury site. | |

| |If limb is severely deformed, cyanotic (bluish), or lacks distal pulses, align with gentle traction. | |

| |Basics of Splinting—Splinting Joint Injuries | |

|5 |Look for paresthesia (tingling) or paralysis. | |

| |Assess the pulse and motor and sensory function below the injury site. | |

| |If distal extremity is cyanotic (bluish) or lacks distal pulses, align with gentle traction; stop if pain or | |

| |crepitus increases. | |

| |Basics of Splinting—Traction Splinting |Discussion Question |

|3 |Use for fractured femur. |What is the mechanism by which traction splinting works? |

| |Reduces diameter of thigh | |

| |Decreases space in which bleeding can occur | |

| |Do not use in the following instances. | |

| |Injury is within one to two inches of the knee or ankle. | |

| |Knee itself is injured. | |

| |Hip is injured. | |

| |Pelvis is injured. | |

| |There is partial amputation or avulsion with bone separation. | |

| |Basics of Splinting—Splinting Specific Injuries | |

|2 |Special techniques may be applied to the splinting of suspected bone and joint injuries to specific sites. | |

| |Review splinting techniques for the shoulder, upper arm, elbow, forearm, wrist, hand, fingers, pelvis, hip, thigh, | |

| |knee, lower leg, ankle, and foot in EMS Skills 30-07 and 30-08. | |

| |Basics of Splinting—Pelvic Fracture | |

|5 |Pneumatic Antishock Garment (PASG) can splint pelvis and decrease compartment size to reduce bleeding. | |

| |Commercial pelvic splint is another method. | |

| |Improvised pelvic wrap may be applied if necessary. | |

| |Fold a sheet lengthwise to eight-inch width. | |

| |Slide it under the small of the back, then down under the pelvis until centered. Ends of the sheet must be of equal| |

| |length on both sides of patient. | |

| |Cross tail ends over patient and twist until sheet is tightly secured around pelvis. | |

| |Tuck sheet ends under patient or tie into square knot. | |

| |Place patient on backboard or rigid device. | |

| |Basics of Splinting—Compartment Syndrome |Discussion Question |

|5 |May occur when fracture or injury to an extremity has occurred |What is compartment syndrome? |

| |May occur in buttocks or abdomen | |

| |Occurs when pressure in space around capillaries exceeds pressure needed to perfuse tissues; blood flow is cut off |Critical Thinking Discussion |

| |and cells become hypoxic. |What causes the pain and paresthesia associated with |

| |Usually develops over time as edema around injured area increases |compartment syndrome? |

| |Commonly associated with fractures, bleeding from trauma, crush injuries, and high-energy trauma | |

| |Signs and symptoms | |

| |Severe pain or burning sensation | |

| |Decreased strength in extremity | |

| |Paralysis of extremity | |

| |Pain with movement | |

| |Extremity feeling hard to palpitation | |

| |Distal pulses, motor, and sensory function possibly normal | |

| |Treatment | |

| |Immobilize and splint affected extremity. | |

| |Elevate extremity and apply cold pack or ice. | |

| |Transport the patient as soon as possible. | |

| |XX. Follow-Up |Case Study Follow-Up Discussion |

|10 |Answer student questions. |Do you agree with the choice of splints? Why or why not? |

| |Case Study Follow-Up | |

| |Review the case study from the beginning of the chapter. |Class Activity |

| |Remind students of some of the answers that were given to the discussion questions. |Alternatively, assign each question to a group of students and|

| |Ask students if they would respond the same way after discussing the chapter material. Follow up with questions to |give them several minutes to generate answers to present to |

| |determine why students would or would not change their answers. |the rest of the class for discussion. |

| |Follow-Up Assignments | |

| |Review Chapter 30 Summary. |Teaching Tips |

| |Complete Chapter 30 In Review questions. |Answers to In Review and Critical Thinking questions are in |

| |Complete Chapter 30 Critical Thinking. |the appendix to the Instructor’s Wraparound Edition. Advise |

| |Assessments |students to review the questions again as they study the |

| |Handouts |chapter. |

| |Chapter 30 quiz |The Instructor’s Resource Package contains handouts that |

| | |assess student learning and reinforce important information in|

| | |each chapter. This can be found under mykit at |

| | |. |

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MASTER TEACHING NOTES

• Case Study Discussion

• Teaching Tips

• Discussion Questions

• Class Activities

• Media Links

• Knowledge Application

• Critical Thinking Discussion

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